Corrective Action Plans

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The payments made with grant funding have been reclassed to the general fund and all future expenditures for the subgrant will be made through the general fund.
The payments made with grant funding have been reclassed to the general fund and all future expenditures for the subgrant will be made through the general fund.
A certified letter has been sent to the overpaid employee requesting the amount be paid back to the school board. Bernice Darby, Payroll Bookkeeper, will follow up monthly until payment is made in full. The district is currently working on an electronic timekeeping system to help eliminate human err...
A certified letter has been sent to the overpaid employee requesting the amount be paid back to the school board. Bernice Darby, Payroll Bookkeeper, will follow up monthly until payment is made in full. The district is currently working on an electronic timekeeping system to help eliminate human error in the future.
The underpaid employee has already been paid the amount owed. The salary for the employee paid by grant funds has been reclassed to the general fund. In addition to the grant accountant, the grant secretary will begin reviewing monthly those employees paid by the grant to ensure this doesn’t happen ...
The underpaid employee has already been paid the amount owed. The salary for the employee paid by grant funds has been reclassed to the general fund. In addition to the grant accountant, the grant secretary will begin reviewing monthly those employees paid by the grant to ensure this doesn’t happen again.
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongo...
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongoing
AUDIT FINDING Finding 2025-001 NSLDS Status Reporting Error MANAGEMENT'S COMMENTS ON FINDINGS AND RECOMMENDATIONS MANAGEMENT'S We concur with the auditor’s finding and identification of a deficiency in our internal controls. CORRECTIVE ACTION PLAN We will enact stronger controls to ensure that all f...
AUDIT FINDING Finding 2025-001 NSLDS Status Reporting Error MANAGEMENT'S COMMENTS ON FINDINGS AND RECOMMENDATIONS MANAGEMENT'S We concur with the auditor’s finding and identification of a deficiency in our internal controls. CORRECTIVE ACTION PLAN We will enact stronger controls to ensure that all future enrollment reporting is submitted timely. EMPLOYEE/ DIVISION RESPONSIBLE Financial Aid Director TIMELINE AND ESTIMATED COMPLETION DATE Immediately
Finding 2025-001 Condition The change in student status for 3 of the 60 students tested was not reported to the National Student Loan Data Systems (NSLDS) within 30 days or included in a response to a roster file within 60 days. The status for 1 of 60 students tested was inaccurately reported to NSL...
Finding 2025-001 Condition The change in student status for 3 of the 60 students tested was not reported to the National Student Loan Data Systems (NSLDS) within 30 days or included in a response to a roster file within 60 days. The status for 1 of 60 students tested was inaccurately reported to NSLDS. Corrective Action Plan The Registrar completed an analysis of each of the changes in student status that were not reported timely or accurately. The following actions have been implemented to improve processes and to reduce the likelihood of noncompliance. The College has instituted a more stringent Incomplete policy for graduate students that aligns with the mandatory NSLDS reporting deadlines of 30 days for status changes and 60 days for roster file responses. The Registrar's Office has established a manual communication protocol requiring staff members who process student status changes outside regular reporting cycles (mid-semester withdrawals, off-cycle graduations, leaves of absence, late grade changes affecting enrollment status) to immediately notify the designated NSLDS reporting staff member via email or direct communication. All staff members processing degree conferrals have been trained. In addition, standing interdepartmental meetings have been established to improve communications. The NSLDS reporting staff member maintains a simple log to track these notifications and ensure timely submission to NSLDS. Registrar's Office is working directly with their NSC analyst to align the Summer Graduates Only reporting windows and all other NSC reporting deadlines with the 30-day and 60-day NSLDS requirements. Name of Contact Person Responsible for Corrective Action: Elizabeth Brentzel Anticipated Completion Date: Spring 2026
SEE SEFA REPORT FOR CAP ON FINDING 2025-002
SEE SEFA REPORT FOR CAP ON FINDING 2025-002
SEE SEFA REPORT FOR CAP ON FINDING 2025-001
SEE SEFA REPORT FOR CAP ON FINDING 2025-001
Management implemented corrective actions to strengthen internal controls over the Data Collection Form submission process, including assigning responsibility to a designated individual and monitoring submission deadlines to ensure timely filing in future periods. Name of contact person responsible ...
Management implemented corrective actions to strengthen internal controls over the Data Collection Form submission process, including assigning responsibility to a designated individual and monitoring submission deadlines to ensure timely filing in future periods. Name of contact person responsible for corrective action plan: Renee Moynagh, Chief Financial Officer. Current Status: The finding has been corrected effective December, 2025.
Management acknowledges the missing internal control over the late submission of the updated financial model/plan for the fiscal year end June 30, 2024. Management has maintained an effective internal control tool for many years in the form of a master spreadsheet called the Annual Task Calendar tha...
Management acknowledges the missing internal control over the late submission of the updated financial model/plan for the fiscal year end June 30, 2024. Management has maintained an effective internal control tool for many years in the form of a master spreadsheet called the Annual Task Calendar that the entire Finance staff reviews at every biweekly Finance meeting, but the WIFIA deadlines were errantly not incorporated into that tool until January 2026. While management agrees with the finding, it should be noted that management was not operating without controls. Rather, the deadline being adhered to was just the wrong date. Management submitted updated financial model/plan by January 31, 2025, which was within the month following the close of the calendar year, similarly to the quarterly construction reports that are due 30 days after the end of the preceding quarter. In addition, the data on the annual model reflected current information near the time of release of the report, not June 30, 2024. So, in substance, management provided an even more current, relevant document. Management acknowledges the additional finding language that the June 30, 2025 quarterly construction monitoring report was submitted on day 31 rather than day 30 following the close of the quarter. Finally, management acknowledges that the annual updated financial model/plan for June 30, 2025, will be submitted in January 2026 as the internal control, as mentioned above, was not corrected until January 2026, which will result in the same finding on the Single Audit for June 30, 2026. However, management believes that we have taken the appropriate measures required to avoid ongoing replication. Responsible Official: Matt Zook, Finance Director
Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. Action(s) Taken or Planned: 2025-001: The underfunded replacement reserve deposit will be deposited into t...
Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. Action(s) Taken or Planned: 2025-001: The underfunded replacement reserve deposit will be deposited into the replacement reserve account as cash flow allows during fiscal year 2026. Furthermore, internal controls over replacement reserve funding are being strengthened to prevent future non-compliance.
The Organization has set up a system to review transfers of federal funding by the Senior Asset Manager and Chief Financial Officer prior to the transfer taking place to ensure it is within the compliance requirements of the grant
The Organization has set up a system to review transfers of federal funding by the Senior Asset Manager and Chief Financial Officer prior to the transfer taking place to ensure it is within the compliance requirements of the grant
The Organization has created a tracking system that identifies when the last inspection was completed and when the next inspection should be due based on the number of units at each complex. NOTE: Inspections are not due until June through October of 2027 for complexes under the jurisdiction of the ...
The Organization has created a tracking system that identifies when the last inspection was completed and when the next inspection should be due based on the number of units at each complex. NOTE: Inspections are not due until June through October of 2027 for complexes under the jurisdiction of the City of Salem.
a. Significant Deficiency - Condition: We noted in our testing of Twenty-First Century reimbursement that claims were not being reviewed before being submitted. B. Plan of action - The responsible officials recognize the need for an improved review process to ensure grant claims are accurate and pro...
a. Significant Deficiency - Condition: We noted in our testing of Twenty-First Century reimbursement that claims were not being reviewed before being submitted. B. Plan of action - The responsible officials recognize the need for an improved review process to ensure grant claims are accurate and properly documented. To address this deficiency, the following actions will be implimented: Role assignment: The Business Manager will prepare and submit each federal grant claim, and the fiscal assistant will conduct a review before final submission. This role assignment will ensure both preparation and indeprendent review are in place. c. Timeline for implimentation: New procedures will be established within the fiscal quarter, with training and full implmentation scheduled by 3/1/2026.
a. material weakness - Condition: During our testing of expenditures charged to the grant, we noted that a paymnet for contracted services was charged to payroll costs. The error was subsequently corrected by the district. Expendituresshould be charged to appropriate account codes. b. Plan of action...
a. material weakness - Condition: During our testing of expenditures charged to the grant, we noted that a paymnet for contracted services was charged to payroll costs. The error was subsequently corrected by the district. Expendituresshould be charged to appropriate account codes. b. Plan of action - The responsible officials recognize the importance of ensuring expenditures are charged to the appropriate account codes. There was a misunderstanding on the form that was filled out for the oregon department of education. This error was corrected with a journal entry. Additionally, the account codes used for federal awards will be reviewed for accuracy on an annual basis. C. Timing: Correcting journal entry was completed on 6/30/2025
Bethany College and Affiliate Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025‐001 – Significant Deficiency in Internal Control Over Compliance – Return of Title IV Funds Condition Found: Four students who had withdrawn from the institution did not have Title IV funds returned to...
Bethany College and Affiliate Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025‐001 – Significant Deficiency in Internal Control Over Compliance – Return of Title IV Funds Condition Found: Four students who had withdrawn from the institution did not have Title IV funds returned to the Department of Education within 45 days. Corrective Action Plan: The College will review our workflow and make oversight improvements to prevent future delays, including standardizing withdrawal notification and handoff procedures, initiating R2T4 calculations immediately upon withdrawal determination, confirming that required COD adjustments are submitted without delay and establishing internal tracking to monitor return activity against the 45 day requirement. Responsible Official for Corrective Action Plan: Sarah Sherinian, Vice President for Student Success & Operational Excellence/Chief Financial Aid Officer
Recommendation: CLA recommends the District review its grant disbursement process to ensure that there is adequate segregation of duties in regards to initiating, authorizing, reviewing for grant allowability and approving purchases, along with adding controls to ensure that the item purchased was r...
Recommendation: CLA recommends the District review its grant disbursement process to ensure that there is adequate segregation of duties in regards to initiating, authorizing, reviewing for grant allowability and approving purchases, along with adding controls to ensure that the item purchased was received by the District. CLA also also recommends the District printout the eligibility reports from Wisegrants and sign and date them to indicate review and approval after meeting with CESA 10 each year. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action planned/taken in response to finding: The District will note the date of the budget meeting with CESA 10. When items are purchased for Title I, approval will be made by either the Elementary Principal or Superintendent before purchases are made. Name(s) of the contact person(s) responsible for corrective action: Brooke Rosemeyer, Adrian Foster, Brandon Baldry Planned completion date for corrective action plan: September 1, 2026.
Child Nutrition Cluster (School Breakfast Program, National School Lunch Program, and Summer Food Service Program for Children) – Assistance Listing No. 10.553, 10.555, and 10.559 Recommendation: CLA recommends that the District review its internal controls and implement a procedure to ensure all re...
Child Nutrition Cluster (School Breakfast Program, National School Lunch Program, and Summer Food Service Program for Children) – Assistance Listing No. 10.553, 10.555, and 10.559 Recommendation: CLA recommends that the District review its internal controls and implement a procedure to ensure all reports required under the grant have a designated reviewer that is different from the individual responsible for preparing, even when there are gaps of coverage in preparer and reviewer positions, and that the review and approval happens prior to submitting the reports to the granting agency. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action planned/taken in response to finding: The Food Service Director and the Executive Administrative Assistant will work together to ensure that procedures are in place to review and confirm for accuracy. Name(s) of the contact person(s) responsible for corrective action: Frankie Soto, Dawn Rausch Planned completion date for corrective action plan: September 1, 2026.
Child Nutrition Cluster (School Breakfast Program, National School Lunch Program, and Summer Food Service Program for Children) – Assistance Listing No. 10.553, 10.555, and 10.559 Recommendation: CLA recommends the District review its procurement process to ensure that there is adequate segregation ...
Child Nutrition Cluster (School Breakfast Program, National School Lunch Program, and Summer Food Service Program for Children) – Assistance Listing No. 10.553, 10.555, and 10.559 Recommendation: CLA recommends the District review its procurement process to ensure that there is adequate segregation of duties in regards to initiating, authorizing, reviewing for grant allowability and approving all procurement transactions. CLA also recommends that the District review and update policies and procedures to help ensure that all federal grants with covered transactions have vendors reviewed for suspension and debarment status prior to entering into the transaction and that documentation of the status is maintained with the procurement history of each transaction that it is required for. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action planned/taken in response to finding: The Food Service Director and the Executive Administrative Assistant and District Administrator will work together to ensure that procedures are in place to review and confirm for accuracy. Name(s) of the contact person(s) responsible for corrective action: Frankie Soto, Dawn Rausch, Adrian Foster Planned completion date for corrective action plan: September 1, 2026.
Child Nutrition Cluster (School Breakfast Program, National School Lunch Program, and Summer Food Service Program for Children) – Assistance Listing No. 10.553, 10.555, and 10.559 Recommendation: CLA recommends that the District implement formal procedures to strengthen controls over eligibility det...
Child Nutrition Cluster (School Breakfast Program, National School Lunch Program, and Summer Food Service Program for Children) – Assistance Listing No. 10.553, 10.555, and 10.559 Recommendation: CLA recommends that the District implement formal procedures to strengthen controls over eligibility determinations. These procedures should include ensuring timely updates to eligibility listings when students become ineligible, retaining all required documentation for the applicable retention period, and conducting periodic reviews of benefit issuance listings to confirm accuracy. Additionally, CLA recommends the District implement procedures to ensure staff receive training on proper eligibility determination and recordkeeping requirements. Finally, CLA recommends the District establish monitoring controls to verify that benefits are discontinued promptly for students who no longer qualify. Eligibility determinations should be reviewed and approved by someone other than the person entering the applications and direct certification information into the software. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action planned/taken in response to finding: The Food Service Director, high school secretary and the Executive Administrative Assistant will work together to ensure that procedures are in place to review and confirm for accuracy. Name(s) of the contact person(s) responsible for corrective action: Frankie Soto, Dawn Rausch, Emily Krzyzanowski Planned completion date for corrective action plan: September 1, 2026.
The security deposit discrepancy will be rectified
The security deposit discrepancy will be rectified
The Salvation Army submitted a BBRI which requested increased rents and releases from reserves to pay accounts payable as well as approval of loans from the Sponsor to cover accounts payable that could not be paid from reserves. This would enable the reserves to be paid on a go forward basis. In add...
The Salvation Army submitted a BBRI which requested increased rents and releases from reserves to pay accounts payable as well as approval of loans from the Sponsor to cover accounts payable that could not be paid from reserves. This would enable the reserves to be paid on a go forward basis. In addition, the next step will be a BBRI for the RAD for PRAC conversion.
The Salvation Army submitted a BBRI which requested increased rents and releases from reserves to pay accounts payable as well as approval of loans from the Sponsor to cover accounts payable that could not be paid from reserves. This would enable the reserves to be paid on a go forward basis. In add...
The Salvation Army submitted a BBRI which requested increased rents and releases from reserves to pay accounts payable as well as approval of loans from the Sponsor to cover accounts payable that could not be paid from reserves. This would enable the reserves to be paid on a go forward basis. In addition, the next step will be a BBRI for the RAD for PRAC conversion.
4. Deficiency #4 – SA-2025-001 a. Federal Award Program – 84.425 ESSER During our testing of ESSER, we noted 2 employees where I9s were not retained. RECOMMENDATION: We recommend the District retain all I9s in accordance with federal law. b. The Director of Financial Services is in communication wit...
4. Deficiency #4 – SA-2025-001 a. Federal Award Program – 84.425 ESSER During our testing of ESSER, we noted 2 employees where I9s were not retained. RECOMMENDATION: We recommend the District retain all I9s in accordance with federal law. b. The Director of Financial Services is in communication with the Director of Human Resources regarding this issue. Human Resources is developing a review process to identify non-compliant i9s and implementing a new staff training program for proper completion, correction and replacement of I9 documents. c. This will be implemented as of June 30, 2026.
1. Hire a Revenue Cycle Liaison o Designate a dedicated Revenue Liaison who will serve as the primary trainer and subject matter expert for the Sliding Fee Discount Program under the Revenue Cycle Director. o Responsibilities include developing training materials, conducting onboarding sessions, and...
1. Hire a Revenue Cycle Liaison o Designate a dedicated Revenue Liaison who will serve as the primary trainer and subject matter expert for the Sliding Fee Discount Program under the Revenue Cycle Director. o Responsibilities include developing training materials, conducting onboarding sessions, and serving as the point of contact for SFDP-related questions. o Estimated Time of Completion: • 1–2 weeks for interviews and selection • 2–3 weeks for onboarding, access setup, and curriculum review • Liaison fully functional by mid-January 2026 2. Immediate Staff Retraining o Retrain all staff involved in SFDP on program requirements, eligibility criteria, and correct implementation of sliding fee determination and billing. o Training will include real-world scenarios, documentation standards, and compliance checkpoints to ensure accuracy. o Quarterly training will be conducted for all Clinic Managers, Front Office staff and Call Center staff. o The topics at these courses covered: i. The overall philosophy and purpose of collecting accurate data. ii. Definition of income; how to accurately calculate income. iii. Definition of family size / household. iv. The call center role in scheduling the patient appointments and how to set the document expectations. v. The importance of collecting all necessary forms and documents from patients in order to insert their financial status into MCC sliding fee scale. vi. How to enter accurate information into all the applicable forms in the EHR. vii. Operational workflow. o Estimated Time of Completion • Retraining will start after the Liaison is fully operational. • Retraining Start: Early to Mid-February 2026 • Retraining Completion: Late February 2026 3. Periodic Compliance Audits o Compliance department will perform independent audits of SFDP transactions on a quarterly basis. o Findings will be reported to senior leadership and incorporated into compliance risk assessments. o Findings will be used for ongoing training and process improvement across all clinics. o Estimated Time of Completion • First audit period: January–March 2026 • Report delivered: April 2026 4. Ongoing Staff Retraining Based on Audit Outcomes o Use audit results to identify gaps and retrain staff accordingly. o Maintain a continuous improvement cycle to ensure adherence to SFDP policies and minimize errors. o Estimated Time of Completion • First audit period: January–March 2026 • Report delivered: April 2026 5. Monthly Peer review o Each supervisor will review a random sample of applications from a different clinic (not their own). o Any discrepancies will be corrected promptly and communicated to the originating clinic. o Results will be tracked monthly to identify trends and target training needs. o Estimated start date will be in March 2026 o The result will be assessed to determine the duration of this review. Responsible- Multiple team members share responsibility for accurately documenting and preserving these records in the correct patient charts. This includes the Clinic Manager, Front Office Supervisors, and the Director of Revenue Cycle. Ultimately, MCC views this as a measure that the Chief Financial Officer and Director of Revenue Cycle all hold responsibility to ensure this policy is adhered to closely. Contact person for Corrective Action Plan listed above: Bharatha Naotunne, CFO Email: bnaotunne@marinclinic.org
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