Corrective Action Plans

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CFDA 10.565 Commodity Supplemental Food Program Name of Contact Person: Shelly Neeley, Program Specialist Corrective Action: Eligibility requirements regarding the Commodity Supplemental Food program (CSFP) are recognized by West Ohio Food Bank (WOFB) and WOFB continues making internal controls a to...
CFDA 10.565 Commodity Supplemental Food Program Name of Contact Person: Shelly Neeley, Program Specialist Corrective Action: Eligibility requirements regarding the Commodity Supplemental Food program (CSFP) are recognized by West Ohio Food Bank (WOFB) and WOFB continues making internal controls a top priority in the program’s operation. There are currently 1,800 applications processed through WOFB and 43 site locations for CSFP. These include those applicants on the active list and the wait list as well as those who may not qualify for the program. During the auditing process, there were 11 participants that did not have a current/updated application on file yet received a distribution. To ensure that all applications are renewed within a twelve-month period, and that the recipients without a valid application on file do not receive distributions until a valid, up-to-date application has been obtained, WOFB has begun to implement and will continue implementing the following internal control procedures. WOFB will continue to update/renew all applications each March to have all expiration dates within the same month each year. The master spreadsheet has also been updated to include parameters that will flag an upcoming expiration date. This will assist the senior sites in knowing more timely who needs a renewal application at their location. In addition, Pantry Trak/Fresh Trak is being updated and revised. I have been working closely with Mid-Ohio in revising the CSFP portion to better meet the needs of the program at WOFB. The ultimate goal is to use the Pantry Trak system to log and track all CSFP information electronically. This too will increase the accuracy of the data. As an additional audit of accuracy WOFB will conduct an internal audit monthly by randomly pulling a sampling of 3 percent (48) of the 1,600 CSFP recipients to verify the accuracy of the applications on file. Proposed Completion Date: The processes implemented will be ongoing. As the Pantry Trak program tool continues to improve its use for tracking and logging, use for CSFP will increase.
Finding 2025-001 Significant Deficiency in Internal Control over Compliance - Reporting AL# 10.553 & 10.555 – Child Nutrition Cluster Corrective Action Plan Employee re-alignment and training was initiated beginning in August 2025, as well as revision to the review process for meal counts to include...
Finding 2025-001 Significant Deficiency in Internal Control over Compliance - Reporting AL# 10.553 & 10.555 – Child Nutrition Cluster Corrective Action Plan Employee re-alignment and training was initiated beginning in August 2025, as well as revision to the review process for meal counts to include a second review prior to submission. In addition, the new system was evaluated for proper configuration to mitigate further issues. Person(s) Responsible M. Thorne, Operations Coordinator Anticipated Completion Date Corrective actions were substantially completed by October 2025.
Monitoring over federal awards – The District has corrected the reporting error for ESSER fund expenditures and is increasing its monitoring responsibilities to meet the needs of federal programs in the future. The District will be developing controls over reporting of federal funds to ensure these ...
Monitoring over federal awards – The District has corrected the reporting error for ESSER fund expenditures and is increasing its monitoring responsibilities to meet the needs of federal programs in the future. The District will be developing controls over reporting of federal funds to ensure these funds reconcile to the general ledger going forward.
Reporting - Federal Awards and Expenditures - ESSER – The District has corrected the reporting error for ESSER fund expenditures and is increasing its monitoring responsibilities to meet the needs of federal programs in the future. The District will be developing controls over reporting of federal f...
Reporting - Federal Awards and Expenditures - ESSER – The District has corrected the reporting error for ESSER fund expenditures and is increasing its monitoring responsibilities to meet the needs of federal programs in the future. The District will be developing controls over reporting of federal funds to ensure these funds reconcile to the general ledger going forward.
Student Financial Aid Cluster – Assistance Listing No. 84.063 & 84.268 Recommendation: We recommend that the District design and implement controls over the review of report parameters and enrollment reporting to ensure financial aid software is properly calculate enrollment based on enrolled credit...
Student Financial Aid Cluster – Assistance Listing No. 84.063 & 84.268 Recommendation: We recommend that the District design and implement controls over the review of report parameters and enrollment reporting to ensure financial aid software is properly calculate enrollment based on enrolled credits at the District. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The report builder has been rebuilt, and the enrollment statuses identified have been updated. The District is actively working with NSC to correct statuses for students who were inadvertently impacted in previously submitted files. Name(s) of the contact person(s) responsible for corrective action: Laurie Grigg, Chief Financial Officer Planned completion date for corrective action plan: June 30, 2026
Contact Person David Drapeaux Corrective Action Plan This finding was resolved in FY2025 through a joint agreement between the District and NDDPI. The questioned costs of $86,171, that were discovered during a separate NDDPI monitoring process, were all returned to the state before the beginning of ...
Contact Person David Drapeaux Corrective Action Plan This finding was resolved in FY2025 through a joint agreement between the District and NDDPI. The questioned costs of $86,171, that were discovered during a separate NDDPI monitoring process, were all returned to the state before the beginning of the 2025 audit. This issue is resolved. Completion Date 05/08/25
Special Education Cluster (IDEA) – Assistance Listing No. 84.027/84.173/ Recommendation: We recommend the district add internal controls over monitoring vendor purchases throughout the fiscal year and comparing them to procurement policies to ensure proper procedures are followed in accordance with ...
Special Education Cluster (IDEA) – Assistance Listing No. 84.027/84.173/ Recommendation: We recommend the district add internal controls over monitoring vendor purchases throughout the fiscal year and comparing them to procurement policies to ensure proper procedures are followed in accordance with 2 CFR 200.319. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will continue to review its internal controls and modify policies and procedures, as necessary. Additional training will be attended by staff to rectify this matters for future years. Name(s) of the contact person(s) responsible for corrective action: Julie A. Stone, Director of Business Services Planned completion date for corrective action plan: The District plans to have the finding corrected by the reporting period ending June 30, 2026.
Recommendations: The District should put controls in place that require contractors performing contract work valued at more than $2,000 and paid with federal funds to submit the required payroll reports, per the Wage Rate Requirements, throughout the contract work. Action Taken: We agree with the re...
Recommendations: The District should put controls in place that require contractors performing contract work valued at more than $2,000 and paid with federal funds to submit the required payroll reports, per the Wage Rate Requirements, throughout the contract work. Action Taken: We agree with the recommendation. Our targeted implementation date is January 2026
Recommendations: The District should include infrastructure items in the current inventory system. Action Taken: We agree with the recommendation. Our targeted implementation date is January 2026.
Recommendations: The District should include infrastructure items in the current inventory system. Action Taken: We agree with the recommendation. Our targeted implementation date is January 2026.
Goodwill Educates, Inc. acknowledges the finding related to the inclusion of in-kind contribution expenses in a federal reimbursement request. We agree with the auditor’s assessment that this was an isolated error. Upon internal review, we determined that the error stemmed from a misclassification d...
Goodwill Educates, Inc. acknowledges the finding related to the inclusion of in-kind contribution expenses in a federal reimbursement request. We agree with the auditor’s assessment that this was an isolated error. Upon internal review, we determined that the error stemmed from a misclassification during the preparation of the reimbursement documentation. The expenses in question were supported by in-kind contributions and not actual cash disbursements, and therefore should not have been submitted for reimbursement. Corrective action was taken by Goodwill Educates, Inc. and all in-kind contributions submitted for federal reimbursement have been billed to the school by Evansville Goodwill Industries, Inc. and cash disbursements will be made. A reimbursable bill for these in-kind contributions was submitted to Goodwill Educates, Inc. in September 2025 and funds will be disbursed in October 2025. Internal training will be conducted with all Finance staff, contracted with Goodwill Educates, Inc., to review and re-train on proper federal reimbursement procedures. An internal control of two separate finance staff to review all federal reimbursement requests prior to submission will be implemented by the organization in the 4th quarter of 2025.
2025-001 ALN 14.872 – Public Housing Capital Fund Program – Cash Management The CEO agrees with the finding and will follow the Auditor's recommendations as listed on the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Mr. Robert Dull, CEO Projected Completio...
2025-001 ALN 14.872 – Public Housing Capital Fund Program – Cash Management The CEO agrees with the finding and will follow the Auditor's recommendations as listed on the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Mr. Robert Dull, CEO Projected Completion Date: June 30, 2026
Enrollment information was not submitted within the required timeframe by the College. Personnel Responsible for Corrective Action: Dena Norris, Associate Vice Chancellor of Student Financial Services, and Tara Dettmer, Director of Financial Aid – Fiscal Operations Anticipated Completion Date: Corre...
Enrollment information was not submitted within the required timeframe by the College. Personnel Responsible for Corrective Action: Dena Norris, Associate Vice Chancellor of Student Financial Services, and Tara Dettmer, Director of Financial Aid – Fiscal Operations Anticipated Completion Date: Corrective action plan will be implemented by June 30, 2026. Views of Responsible Officials and Planned Corrective Action Plan: Despite best efforts by the College to correct the errors in enrollment reporting, the College experienced turnover among staff, and as a result, was unable to shift staffing resources or quickly hire replacement staff to correct the finding. Metropolitan Community College (MCC) is in the process of hiring additional staff dedicated to enrollment and compliance reporting. MCC will make a random selection of 10-15 students each month to verify data was correctly transmitted to National Student Clearinghouse (NSC). A secondary check of these students will be done to ensure the data is also transmitted to the National Student Loan Data System (NSLDS). MCC will also ensure error reports and other data issues are resolved in a timely manner to ensure reporting of students is completed within the regulatory timeframe. Due to the implementation of a new Enterprise Resource Planning system MCC is also validating and correcting any submission errors.
Sandburg’s procedures require reviewing and clearing all C codes/comment codes that require resolution. 1. We reviewed the recommendation presented, and we have added language to clearly outline procedures to show the decision-making process and documentation steps, depending on the particular code....
Sandburg’s procedures require reviewing and clearing all C codes/comment codes that require resolution. 1. We reviewed the recommendation presented, and we have added language to clearly outline procedures to show the decision-making process and documentation steps, depending on the particular code. Our procedures for identifying and resolving comment codes are compliant with the recommendations. 2. We have enhanced the workflow to go over the ISIR Code resolution process each year before file review begins. 3. We have added procedures to have the reviewer sign off showing the decision, the reviewer's initials and the date when resolution involves a decision as outlined in the FAFSA specifications guide. 4. Training has been completed by the Director of Financial Aid, Associate Director of Financial Aid. Person(s) Responsible: Dustin Zimmerman, Director of Financial Aid Timing for Implementation: Fall 2025
Sandburg reviewed the audit finding regarding NSLDS reporting. We acknowledge the finding and implemented the following corrective action plan: 1. Added an additional NSLDS report following final grades to ensure we are picking up unofficial withdrawals. 2. Updated our reporting schedule with Cleari...
Sandburg reviewed the audit finding regarding NSLDS reporting. We acknowledge the finding and implemented the following corrective action plan: 1. Added an additional NSLDS report following final grades to ensure we are picking up unofficial withdrawals. 2. Updated our reporting schedule with Clearinghouse/NSLDS. 3. Updated written procedures to include a quality control check before the NLSDS/Clearinghouse file is sent. 4. Added an end-of-term quality control spot check to review that unofficial withdrawal submissions went through. 5. Updated written procedures for NSLDS reporting. Procedures are reviewed as regulations change, as our reporting software evolves, and during staff transitions to ensure compliance. 6. Training completed by the Dean of Enrollment Management, Director of Advising, Registrar, Associate Director of Advising & Transfer Coordination, Director of Financial Aid, Coordinator of Financial Aid, Veterans & Military Services. Procedures are reviewed as regulations change and during staff transitions to ensure compliance. Person(s) Responsible: Angela Snow; Director of Advising, Registrar Timing for Implementation: These procedures were implemented by December 2025.
Auditor Description of Condition and Effect: During our audit procedures over the District’s payroll process, we noted that an employee’s wages were allocated to the food service function based on a straight percentage instead actual work performed. As a result of this condition, the District does n...
Auditor Description of Condition and Effect: During our audit procedures over the District’s payroll process, we noted that an employee’s wages were allocated to the food service function based on a straight percentage instead actual work performed. As a result of this condition, the District does not have proper controls in place over its procedures for allocation of wages. Auditor Recommendation: The District should utilize timecards to support the allocation of wages to federal functions. Corrective Action: The District will. Responsible Person: Jamie Johncock, Business Manager Anticipated Completion Date: June 30, 2025
Condition: The Commission did not submit the required financial and performance reports promptly. Planned Corrective Action: The Capital Team Project Manager continues to reconcile HUD’s EPIC and ELOCC systems with Yardi monthly to ensure timely filing of capital projects' closeouts. This tracking c...
Condition: The Commission did not submit the required financial and performance reports promptly. Planned Corrective Action: The Capital Team Project Manager continues to reconcile HUD’s EPIC and ELOCC systems with Yardi monthly to ensure timely filing of capital projects' closeouts. This tracking critical spreadsheet, created by the Lead Performance Officer, will trigger key reporting dates for the DHC Capital Fund Program to remain in compliance with HUD reporting deadlines. At a minimum, monthly, this critical spreadsheet is distributed to the Supervisor of Capital and the Lead Performance Officer to ensure compliance. However, this was on the radar and continues the process of cleaning older items for corporate hygiene. As of December 2025, this was closed out and approved in EPIC by HUD. Contact person responsible for corrective action: Michael Edwards, Capital Asset & Skilled Trades Supervisor Anticipated Completion Date: 12/31/2025
Condition: The Commission did not complete fiscal year 2025 recertifications. Planned Corrective Action: Staff have been retrained on the compliance requirements under the standards of the HCV Program through the oversight of the Rental Assistance Department Manager and Continued Occupancy Superviso...
Condition: The Commission did not complete fiscal year 2025 recertifications. Planned Corrective Action: Staff have been retrained on the compliance requirements under the standards of the HCV Program through the oversight of the Rental Assistance Department Manager and Continued Occupancy Supervisor. The Department Manager and Supervisor continue to utilize all Yardi monitoring reports to ensure the Department is operating in accordance with industry standards. Reporting is be done and monitored monthly to meet set goals. Weekly, Department Manager has review the certification pipeline to ensure compliance and follow up with the Housing Specialist to ensure compliance and meeting set weekly and monthly goals and metrics. We continue to work in accordance with HUD rules and regulations where Annual Recertification processes are concerned. Per HUD communication provided to us, as of June 30, 2025, HCV is 100% compliant with HUD recertification requirements. Contact person responsible for corrective action: Felicia Burris, HCV Program Manager Anticipated Completion Date: 7/1/2025
Condition: The Commission was unable to send failed HQS inspection notices promptly to participants who needed to correct deficiencies. Planned Corrective Action: HCV will hire additional internal support for HQS inspections to work alongside external vendors and ensure timely updates/mailings/, and...
Condition: The Commission was unable to send failed HQS inspection notices promptly to participants who needed to correct deficiencies. Planned Corrective Action: HCV will hire additional internal support for HQS inspections to work alongside external vendors and ensure timely updates/mailings/, and closeouts are uploaded to the work management system, Yardi. Contact person responsible for corrective action: Felicia Burris, HCV Program Manager Anticipated Completion Date: 6/30/2026
November 21, 2025 FINDING 2025-001 – Special Tests and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control over Compliance Otis College of Art and Design agrees with the finding. Upon review of the finding, Financial Aid administration met with Registrar’s staff to create a...
November 21, 2025 FINDING 2025-001 – Special Tests and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control over Compliance Otis College of Art and Design agrees with the finding. Upon review of the finding, Financial Aid administration met with Registrar’s staff to create a new procedure whereby immediate reporting of withdrawals are made directly to NSLDS in addition to the regularly scheduled monthly reports to NSLDS through the National Student Clearinghouse (NSC). This immediate reporting should eliminate any timing issues with the monthly reports through NSC. In addition, a joint effort to streamline the routing of withdrawal forms to the appropriate departments for faster processing is underway. This reprocessing of the withdrawal forms will be implemented in the next 120 days. Responsible Office and Individuals The Executive Director of Financial Aid and The One Stop, Michaela Matsumoto and Registrar, Nicole Raef are the responsible individuals for implementation of the corrective action plan. Corrective Action Plan The Registrar implemented a centralized tracking system that is now used for every withdrawal and graduation status change at all points in the semester. Registration reviews the withdrawal list weekly to ensure each change is accurately reflected in both NSC and NSLDS. To address graduation status updates, we are adjusting the timeline of our final spring enrollment report to NSC so it is submitted at the end of May. This allows NSC to transmit the data to NSLDS at the beginning of June resulting in fewer manual updates in NSLDS. Registration will then review all graduated students to confirm accurate NSLDS reporting rather than relying solely on Clearinghouse submissions. In addition, the Registration office will review and correct the NSC error report on a monthly basis. The Financial Aid and Registration offices will also initiate quarterly meetings to ensure timely submissions and address any emerging issues.
Primary Health Care Corrective Action Plan – Sliding Fee Finding: During the External Financial Audit for FY 2025, it was determined that certain patients had received sliding fee discounts that were not consistent with the stated sliding fee discount categories under PHC’s policy. Action Step Lead ...
Primary Health Care Corrective Action Plan – Sliding Fee Finding: During the External Financial Audit for FY 2025, it was determined that certain patients had received sliding fee discounts that were not consistent with the stated sliding fee discount categories under PHC’s policy. Action Step Lead Support Due Date Update resource materials associated with sliding fee discounts and distribute to necessary staff. Provide training to necessary staff on sliding fee discount policy and any changes to discounts. Beth Frantum, CFO Revenue Cycle Director Patient Services Director March 2026 Develop and implement an internal review process to provide reasonable assurance that Slide calculations are accurate and EPIC reflects the correct amount expected for services. Beth Frantum, CFO Revenue Cycle Director Patient Services Director John Shaw, Director of Clinics April 2026
Child Nutrition Cluster – Assistance Listing No. 10.553, 10.555 and 10.559 Recommendation: The District should review their internal control process for free and reduced meal applications to ensure that the proper controls are being implemented. Explanation of disagreement with audit finding: There ...
Child Nutrition Cluster – Assistance Listing No. 10.553, 10.555 and 10.559 Recommendation: The District should review their internal control process for free and reduced meal applications to ensure that the proper controls are being implemented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The District will revise their internal control process to ensure that the District's controls for free and reduces meal applications are being implemented. Name(s) of the contact person(s) responsible for corrective action: Tim Widiker, Superintendent. Planned completion date for corrective action plan: December 2025.
Finding Synopsis: Amounts were submitted to the state for reimbursement were higher than costs with required supporting documentation. The district had difficulty in providing supporting documentation for the amounts submitted for reimbursement, and expenditures could not be easily separated between...
Finding Synopsis: Amounts were submitted to the state for reimbursement were higher than costs with required supporting documentation. The district had difficulty in providing supporting documentation for the amounts submitted for reimbursement, and expenditures could not be easily separated between the last two fiscal years the grant was received. Action Steps: The district implemeted changes in control activites to ensure that proper review controls are in place and that all grant reimbursements have adequate documentation. Contact Person: Alicia Cieszykowski, Assistant Superintendent for Business Services, 630-295-5430 Anticipated Completion Date: 06/30/2026
The purpose of the Goods Receipt (GR) is to record receipt of goods or services as soon as they are delivered and verified to be in acceptable condition. A Goods receipt must be posted in SAP for all items actually received. Vendors submit invoice(s) referencing the purchase order (PO) directly to A...
The purpose of the Goods Receipt (GR) is to record receipt of goods or services as soon as they are delivered and verified to be in acceptable condition. A Goods receipt must be posted in SAP for all items actually received. Vendors submit invoice(s) referencing the purchase order (PO) directly to Accounts Payable after delivery, indicating that the goods or services have been provided and requesting payment. Accounts Payable then reviews the vendor invoice, purchase order, and goods receipt in SAP to perform the required three-way match (PO, GR, and vendor invoice) before processing payment. 1. The Accounts Payable team will collaborate with the Procurement Services Division to establish and implement a process that ensures the timely review and reconciliation of Goods Receipt (GR) entries. This will include the development of clear guidance / training materials for schools and offices to periodically review their GR balances. Training will be conducted via Virtual Office Hours on a quarterly basis for sites to make necessary adjustments when the goods or services received differ from the original Purchase Order (PO) or the corresponding invoice. 2. The Accounts Payable team will collaborate with the Procurement Services Division to develop supplemental documentation and guidance regarding proof of delivery for goods and services received. 3. Accounts Payable staff will receive ongoing training throughout the year on documentation and reconciliation requirements, particularly when new internal controls, procedures, and processes are created. Training will be incorporated into regular team meetings, procedural updates, and onboarding for new team members to maintain alignment and accuracy across the department. The implementation target date for the above corrective action plan is June 30, 2026. Name: Rocio Saucedo Title: Director of Accounts Payable Contact Information: Rocio.Saucedo@lausd.net
Payroll Administration concurs with the recommendation pertaining to the preparation, review, and approval of employee timesheets to ensure the accuracy and completeness of payroll records. Employee timesheets and payroll records are originated, reviewed, and retained at the respective work location...
Payroll Administration concurs with the recommendation pertaining to the preparation, review, and approval of employee timesheets to ensure the accuracy and completeness of payroll records. Employee timesheets and payroll records are originated, reviewed, and retained at the respective work locations. Therefore, Payroll Administration does not have direct access to these site-level records. To strengthen compliance, Payroll Administration will continue to provide targeted training and guidance to time reporters and time approvers on the timely review and approval of timesheets, the required time and effort certification, as well as the reconciliation of timesheet data with SAP entries. These topics will be reinforced during the monthly Time Reporter and Time Approver Virtual Office Hours. Furthermore, Payroll Administration will continue to issue periodic communications and disseminate the Best Practices Worksheet, which outlines key payroll compliance requirements, including adherence to payroll cut-off deadlines and reconciliation of timesheets and time entry in SAP. Payroll Administration remains committed to supporting District departments and school sites in maintaining full compliance with established payroll policies and procedures. Name: Araceli Pineda Title: Director, Payroll Administration Contact Information: araceli.pineda@lausd.net
The Food Services Division is committed to providing great food and maintaining rigorous internal controls and continuous monitoring to safeguard program integrity. The discrepancy found at one school is not representative of our program, as we do ongoing random audits of submitted claims to verify ...
The Food Services Division is committed to providing great food and maintaining rigorous internal controls and continuous monitoring to safeguard program integrity. The discrepancy found at one school is not representative of our program, as we do ongoing random audits of submitted claims to verify the accuracy of submitted data. These layered oversight measures provide multiple levels of verification to minimize and eliminate the likelihood of reporting errors and ensure compliance with applicable state and federal program requirements. At Annalee El, the school with an overclaim of 104 meals, we found that the manager had moved from the school, and in the interim, our review protocol fell short. Given the large volume of meals served annually across the District, the over-claim discrepancy identified during the FY 24-25 audit represents an isolated incident rather than a systemic deficiency in LAUSD Food Services operations. The claim verification process followed at schools is stated below: • The Food Service Manager conducts a weekly review of the prior week’s daily meal count documents to identify and correct any discrepancies. • The Food Service Manager generates and reviews a weekly Meal Counts Report from the Cafeteria Management System (CMS) to verify recorded data. • The Food Service Manager compares the daily meal count documents against the five-day Meal Counts Report to ensure data alignment and accuracy. • The Manager performs an additional verification by reconciling daily meal count documents with the five-day Meal Counts Report from CMS. Any identified errors are corrected immediately in CMS. This reconciliation process is completed prior to the submission of claims to the Child Nutrition Information and Payment System. • The Area Food Services Supervisor (AFSS) and Regional Manager (RM) conduct random weekly reviews of meal counts for accuracy, utilizing reports provided by Central Office staff to support this verification process. • Central Office staff perform a monthly audit of meal count records and prepare a draft report for review by the AFSS and RM to validate findings and confirm accuracy. Retraining of the staff at Annalee El has been completed, and the manager and supervisor teams are verifying that the above protocol is being followed consistently at all schools. Name: Manish Singh Title: Director, Food Services Division Telephone: (213) 241-2993
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