Corrective Action Plans

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Name of Contact Person: Karen Gillis Corrective Action Plan: As mentioned in the corrective action plan for finding 2025-001, we have instructed our attorney’s office to develop language for the new Subaward Agreement outlining a new process for verifying single audit requirements and how we will fo...
Name of Contact Person: Karen Gillis Corrective Action Plan: As mentioned in the corrective action plan for finding 2025-001, we have instructed our attorney’s office to develop language for the new Subaward Agreement outlining a new process for verifying single audit requirements and how we will follow up on any findings identified in audits associated with our subrecipients. Our process will identify the level of risk as well as a criterion for evaluating risk, a timeline for our request and review of audits and a correspondence schedule to include monitoring a subrecipient’s adherence to corrective action plans. In the end, BSFA will have a policy and process to annually assess subrecipient federal expenditures to determine single audit requirements, obtain and review subrecipient audit reports, including follow-up on any findings, document management decision and track corrective action until resolution. Proposed Completion Date: June 30, 2026
Name of Contact Person: Karen Gillis Corrective Action Plan: We have submitted our Subaward Agreement Template to our attorney’s office for review of compliance in all segments of the Agreement Template. Once we receive the new version we will work with all Subaward partners to update the agreements...
Name of Contact Person: Karen Gillis Corrective Action Plan: We have submitted our Subaward Agreement Template to our attorney’s office for review of compliance in all segments of the Agreement Template. Once we receive the new version we will work with all Subaward partners to update the agreements for the current term of their awards. We will also use the new version for all awards hereafter. Proposed Completion Date: June 30, 2026
Condition: The College did not send out the post-disbursement email notifications to a group of students. Planned Corrective Action: While the University has documented procedures in place for the disbursement of federal funds and required post-disbursement notifications to students, the finding ide...
Condition: The College did not send out the post-disbursement email notifications to a group of students. Planned Corrective Action: While the University has documented procedures in place for the disbursement of federal funds and required post-disbursement notifications to students, the finding identified related to only students who received both a Federal PLUS loan and a Federal Direct Loan during 2025. University did not properly send a post-disbursement notification to 117 out of 247 students who received both a federal PLUS loan as well as a Federal Direct Loan on a specific date during fiscal year 2024-2025. The University will adjust its internal processes to ensure all students who receive federal loans are sent post-disbursement email notifications by performing a review of the IT system and working toward fully automated notification settings to ensure all students are captured in the post-disbursement notification process. Contact person responsible for corrective action: Leah Alderink, Director of Student Financial Aid Anticipated Completion Date: Immediately
FINDING 2025-004 Finding Subject: COVID-19 Education Stabilization Fund – Matching, Level of Effort, Earmarking Contact Person Responsible for Corrective Action: Jennifer Miller, Corporate Treasurer Contact Phone Number and Email Address: 765-689-9131; millerje@maconaquah.k12.in.us Views of Responsi...
FINDING 2025-004 Finding Subject: COVID-19 Education Stabilization Fund – Matching, Level of Effort, Earmarking Contact Person Responsible for Corrective Action: Jennifer Miller, Corporate Treasurer Contact Phone Number and Email Address: 765-689-9131; millerje@maconaquah.k12.in.us Views of Responsible Officials: We concur with the Finding Response Comments: When the initial budget was set up for this Grant, it was not set up correctly to track the 20% learning loss for this Federal Grant. The Grant has now closed and is no longer being used. In the future, any Grants that must show level of effort, will be set up by the Corporate Treasurer in the accounting software to better track the level of effort or any matching funds. Anticipated Completion Date: This grant is closed and there is no need for a corrective action
FINDING 2025-003 Finding subject: COVID-19 Educational Stabilization Fund – Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Jennifer Miller, Corporate Treasurer Contact Phone Number and Email Address: 765-689-9131 millerje@maconaquah.k12.in.us Views of Responsible O...
FINDING 2025-003 Finding subject: COVID-19 Educational Stabilization Fund – Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Jennifer Miller, Corporate Treasurer Contact Phone Number and Email Address: 765-689-9131 millerje@maconaquah.k12.in.us Views of Responsible Officials: We concur with the finding According to our Classified Handbook, we only have a starting wage stated for employees. This handbook is in place for the 2025-2026 and 2026-2027 school years. We will take action to update the handbook for the 2026-2027 school year to include a starting and ending wage for the classified positions listed within the Classified Employee Handbook. This action will need to be voted on by the School Board. Anticipated Completion Date: August 2026
FINDING 2025-002 Finding Subject: Child Nutrition Cluster – Allowable Costs/Costs Principles Contact Person Responsible for Corrective Action: Jennifer Miller, Corporate Treasurer Contact Phone Number and Email Address: 765-689-9131; millerje@maconaquah.k12.in.us Views of Responsible Officials: We c...
FINDING 2025-002 Finding Subject: Child Nutrition Cluster – Allowable Costs/Costs Principles Contact Person Responsible for Corrective Action: Jennifer Miller, Corporate Treasurer Contact Phone Number and Email Address: 765-689-9131; millerje@maconaquah.k12.in.us Views of Responsible Officials: We concur with the findings Response Comments: According to our Classified Handbook, we only have a starting wage stated for employees. This handbook is in place for the 2025-2026 and 2026-2027 school years. We will take action to update the handbook for the 2026-2027 school year to include a starting and ending wage for the classified positions listed within the Classified Employee Handbook. This will need to voted on by the School Board before we can put into practice. Anticipated Completion Date: August 2026
Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airport Programs; We recommend that the City implement a reporting system that requires all employees paid with federal funds to complete itemized, signed timesheets detailing the specific hours worked on each...
Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airport Programs; We recommend that the City implement a reporting system that requires all employees paid with federal funds to complete itemized, signed timesheets detailing the specific hours worked on each grant or project on a daily or weekly basis. These timesheets must be reviewed and approved by a supervisor with firsthand knowledge of the work performed.; Management's Response: The City of Red Bluff has used a log of time spent on the grant including date, description of activity, and time worked on the grant. The logs failed to account for non-grant related time as required by 2 CFR 200.430(g)(1)(iv).; Responsible Individual: Leanna Pearson, Assistant Finance Director; Corrective Action Plan: The City will set up separate tracking within the job category in the City’s payroll timekeeping software for grants. The employee will split the time in the timekeeping software and add notes describing the activities and grants worked on.; Anticipated Completion Date: 3-4-2026.
Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Aiport Programs; We recommend that the City establish a tracking system to monitor all required reports and their due dates to ensure timely submission. Management's Response: City of Red Bluff contracts out a...
Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Aiport Programs; We recommend that the City establish a tracking system to monitor all required reports and their due dates to ensure timely submission. Management's Response: City of Red Bluff contracts out airport grant compliance to a third-party contractor. The scope of services in that contract end at the completion and submittal of the grant closeout documents. Delays in the Federal Government review and comment of grant closeout documents have left a period where the final closeout documents have been submitted but the grant is not closed. In the period when the final closeout documents have been submitted but the grant was not closed, the City was required to submit annual SF-425 reporting package and will continue to be required to file the annual SF-425 reporting package until the Federal Government can process the closeout documents. This period was erroneously left out of the scope of services for the third-party contractor grant compliance, and the City failed to submit the proper reports.; Responsible Individual: Scott Miller, Public Works Director; Corrective Action Plan: The City will add to the scope of services template language to add compliance period of between submittal of the grant closeout documents and acceptance of those documents. The City will then monitor the contract for these new services. The City will also file the missing SF-425 forms.; Anticipated Completion Date: 4-30-2026
Community Development Block Grants/State's Program and Non-Entitlement Grants in Hawaii. We recommend that the management strengthen controls over disbursements by ensuring that no payment is processed without a valid, itemized invoice that has been approved by authorized personnel. Furthermore, all...
Community Development Block Grants/State's Program and Non-Entitlement Grants in Hawaii. We recommend that the management strengthen controls over disbursements by ensuring that no payment is processed without a valid, itemized invoice that has been approved by authorized personnel. Furthermore, all supporting documentation should be attached to the payment voucher and retained for audit procedures. Management's Response: The City agrees, and controls will be strenthened over disbursements, and all supporting documentation will be attached and retained for audit procedures. Responsible Individual: Wendy Howard, Finance Director. Corrective Action Plan: Management has strengthened internal controls over disbursements. All payments will be supported by valid, itemized invoices and approved by authorized personnel. Supporting documentation will be attached prior to payment and retained for audit purposes.
Finding 1179396 (2025-001)
Material Weakness 2025
The County Sheriff should review the operating procedures of the office to obtain the maximum internal control possible under the circumstances utilizing currently available staff, including elected officials.
The County Sheriff should review the operating procedures of the office to obtain the maximum internal control possible under the circumstances utilizing currently available staff, including elected officials.
None reported. Finding: 2025-001 Inaccurate Resources Information Entry Name of Contact Person: Lynn Swett, Human Services Deputy Director Corrective Action: Proposed Completion Date: For the Year Ended June 30, 2025 Corrective Action Plan Section II. Financial Statement Findings Section III. Federa...
None reported. Finding: 2025-001 Inaccurate Resources Information Entry Name of Contact Person: Lynn Swett, Human Services Deputy Director Corrective Action: Proposed Completion Date: For the Year Ended June 30, 2025 Corrective Action Plan Section II. Financial Statement Findings Section III. Federal Award Findings and Questioned Costs Corrective Actions for Finding 2025-001 also apply to State Award Findings. Section IV - State Award Findings and Question Costs Staff were re-trained on effective date of change, and how to verify those dates are correct in NC FAST before the continuation of case processing, along with how to verify resources and the proper way to request information and what information is vital to case processing. Policy and procedures were used to ensure staff are trained appropriately. Second party reviews will continue to occur to ensure dates are correct in NC FAST, and second party reviews have increased to target 100% of all applications. The majority of cases found in error were in error prior to this training in December of 2024. Re-training occurs monthly during staff meetings to continue to improve outcomes. More difficult eligibility determination like those involving Special Needs Trust or Pooled Trust will be assigned to senior staff for processing and will immediately be second partied by the supervisor to ensure that resources and income are accounted for properly. Any noted discrepancies will be consulted with State Operation Support Team during processing of case. Second party reviews will continue to occur to ensure accuracy on information entered, including the use of resources. Trainings were completed by December 31, 2024, monthly staff meetings have been used to reinforce those training materials. 136
Finding 1179394 (2025-001)
Material Weakness 2025
None reported Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Corrective actions for findings 2025-001 also apply to the State Awards findings. Section IV - State Award Findings and Questioned Costs All cases now undergo two separate superviso...
None reported Name of Contact Person: Heather Owens - Medicaid Supervisor Corrective Action: Proposed Completion Date: Corrective actions for findings 2025-001 also apply to the State Awards findings. Section IV - State Award Findings and Questioned Costs All cases now undergo two separate supervisory checks: One before the worker disposes of the case. A second check after disposal and worker sign-off to confirm that every identified correction was fully completed. This double-verification step was implemented immediately upon discovery of the issue. Each caseworker now receives a personalized checklist based on errors identified in their secondparty reviews. Workers must complete and submit this checklist at the time of review to acknowledge and address recurring issues. Immediate staff meetings were held to review audit findings and relevant policy. Additional training on correct income rules for recertifications is being developed (due to repeated findings). The supervisor has drafted the material, which will be submitted to State staff for review and approval. Training will be delivered to the entire team no later than the end of December 2025 (subject to State review timeline and holiday schedule). Weekly team meetings continue to cover Medicaid policy updates. Individual one-on-one meetings are held with each worker to review second-party errors, clarify policy, and provide coaching. A lead worker has been designated and is actively in training. The lead worker is already assisting with case staffing and troubleshooting while continuing to deepen her knowledge (particularly in the more complex Adult Medicaid program). Full lead-worker responsibilities are expected to be in place within the next six months. Second-party reviews now include checks of other active cases in the household or agency to ensure required changes are addressed and reported. This practice is reinforced with staff and monitored for compliance. The supervisor will complete a full review of pending COVID-related cases by the end of January 2026, followed by targeted team training on proper ongoing handling. All trainings and policy implementations will be completed by end of January 2026. Finding: 2025-001 Section III - Federal Award Findings and Questioned Costs Corrective Action Plan For Year Ended June 30, 2025 Section II - Financial Statement Findings 159
Finding 2025 – 001: Restatement to Net Position for Capital Assets Condition: During audit fieldwork, our testing resulted in a restatement of net position in order to correct capital assets due to a new appraisal. Plan: The District implemented a new capital asset appraisal in order to have accurat...
Finding 2025 – 001: Restatement to Net Position for Capital Assets Condition: During audit fieldwork, our testing resulted in a restatement of net position in order to correct capital assets due to a new appraisal. Plan: The District implemented a new capital asset appraisal in order to have accurate historical records of all assets owned by the District. These schedules will be updated on an annual basis to reflect accurate reporting requirements. Anticipated Date of Completion: Fiscal Year 2026 Name of Contact Person: Kirsten Perkins, Director of Finance and Human Resource Management Response: The District implemented a new capital asset appraisal in order to accurately reflect historical asset detail. The District will work to update these schedules, including accumulated depreciation on an annual basis. 13
Action Plan - These errors were the result of a new student information system. As part of the implementation process, CIP codes were incorrectly migrated over from our legacy system to the new system (Colleague). This resulted in program enrollment status errors. Corrective Actions Completed: The R...
Action Plan - These errors were the result of a new student information system. As part of the implementation process, CIP codes were incorrectly migrated over from our legacy system to the new system (Colleague). This resulted in program enrollment status errors. Corrective Actions Completed: The Registrar's Office conducted a comprehensive review of all active program CIP codes and corrected all identified discrepancies within the student information system. The Registrar's Office is coordinating with Student Financial Services to verify that the 22 sampled students' enrollment and program statuses are accurately reflected in NSLDS. Corrective Actions in Progress: The Registrar's Office is obtaining direct NSLDS access to ensure the office responsible for enrollment reporting can independently review and validate reported data. Access is expected to be finalized by February 27th, 2026. Preventative Controls: Beginning Spring 2026, the Registrar's Office will implement a recurring end-of-term ntrol review. A sample of 12 students will be selected each semester to verify that enrollment status, program status, and CIP code reporting are accurate between the student information system and NSLDS. Results of this review will be documented and retained, and any discrepancies will be corrected prior to the subsequent enrollment submission. The Registrar believes these corrective measures address the root cause of the finding and strengthen internal controls to ensure ongoing compliance with federal reporting requirements. Responsible Official: Danielle Jeffress, University Registrar Estimated Completion Date: May 30, 2026
The College implemented additional procedures to allow earlier detection of fraud.
The College implemented additional procedures to allow earlier detection of fraud.
The College will perform the mass processing for COD reporting on a more frequent basis to ensure reporting is timely.
The College will perform the mass processing for COD reporting on a more frequent basis to ensure reporting is timely.
The Federal Programs Director, Paula Lovell, will ensure that all employees paid with Title I funds are assigned to eligible Title I positions. Paula Lovell will hold a monthly review meeting with the District Treasurer, Kathryn Powell, to review and monitor Title I expenditures and verify that all ...
The Federal Programs Director, Paula Lovell, will ensure that all employees paid with Title I funds are assigned to eligible Title I positions. Paula Lovell will hold a monthly review meeting with the District Treasurer, Kathryn Powell, to review and monitor Title I expenditures and verify that all salary and benefit payments charged to the program are appropriate.
Condition: During the compliance testing of the Uniform Guidance "Special Tests and Provisions - Sliding Fee Discounts" two (2) selections out of a sample size of forty (40) used the incorrect calculation of income from the proof of income and applied the incorrect sliding fee. Plan: Management will...
Condition: During the compliance testing of the Uniform Guidance "Special Tests and Provisions - Sliding Fee Discounts" two (2) selections out of a sample size of forty (40) used the incorrect calculation of income from the proof of income and applied the incorrect sliding fee. Plan: Management will ensure that all information is collected and input into the billing system correctly in order to avoid patients getting charged incorrect amounts for services. Anticipated Date of Completion: March 31, 2026. Name of Contact Person: Lori Sanson, CFO. Management's Response: Management is implementing weekly chart auditing of encounters from the prior week. These reviews will include a review of the client's financial information which includes assessment of the sliding fee scale paperwork completed, whether we have obtained proof of income, if the sliding fee was entered into the billing system, if the sliding fee adjustments are applied, if payment was collected, insurance information, and the client's balance. These audits will be sent to front office staff for corrections (if needed) or the CFO for review on a monthly basis. In addition, MCPHC Supervisors will obtain a monthly report of the clients that have not turned in proof of income in order to proactively reach out either by phone, email or mail and attempt to obtain the information.
FINDING 2025-001 Finding Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Leeanne Koeneman Contact Phone Number and Email Address: Leeanne.Koeneman@nacs.k12.in.us; 260-637-8768 Views of Responsible Officials: We concur with...
FINDING 2025-001 Finding Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Leeanne Koeneman Contact Phone Number and Email Address: Leeanne.Koeneman@nacs.k12.in.us; 260-637-8768 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School Corporation will design and implement a proper system of internal controls and procedures to ensure there are appropriate procurement procedures for goods and services and contractors and subrecipients, as appropriate, are not suspended, debarred, or otherwise excluded prior to entering any contracts or subawards. This process will include obtaining vendor certifications and/or verification through SAM.gov, with two independent individuals reviewing and confirming the completeness and accuracy of the documentation. Certification will be initialed and retained in the procurement file. Anticipated Completion Date: January 26, 2026 INDIANA STATE
PLANNED CORRECTIVE ACTION - The Davis-Bacon Act requirements to submit weekly payroll certification will be included in all contract language for federally funded projects as well as on our purchase orders. The finance department will continued to follow up with vendors to ensure payroll certificati...
PLANNED CORRECTIVE ACTION - The Davis-Bacon Act requirements to submit weekly payroll certification will be included in all contract language for federally funded projects as well as on our purchase orders. The finance department will continued to follow up with vendors to ensure payroll certifications are collected before invoice payments are made. ANTICIPATED COMPLETION DATE - February 13, 2026 RESPONSIBLE CONTACT PERSON - Shannon Rodriguez, CFO
Name of Contact Person: Robin M. West, Assistant County Manager/Chief Financial Officer Corrective Action/Management Response: Davie County Health and Human Services staff will review documentation supporting claims entered into the NC Fast Enterprise Program Integrity (“EPI”) system for accuracy an...
Name of Contact Person: Robin M. West, Assistant County Manager/Chief Financial Officer Corrective Action/Management Response: Davie County Health and Human Services staff will review documentation supporting claims entered into the NC Fast Enterprise Program Integrity (“EPI”) system for accuracy and completeness. The supervisor reviews all 1682 forms for accuracy and quality control prior to entering the claim into NCFAST. The cases identified in error were the result of training and processing issues related to a former employee. DSS will properly train employees and address any future processing issues immediately through quality control procedures. Proposed Completion Date: Immediately and ongoing.
FINDING 2025-007 Finding Subject: BRIC: Building Resilient Infrastructure and Communities – Internal Controls Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We ...
FINDING 2025-007 Finding Subject: BRIC: Building Resilient Infrastructure and Communities – Internal Controls Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: This grant was fully expended in 2024. Going forward, the current treasurer will work closely with the grant administrator, whether within corporation or an outside source, when compiling all claims, disbursements and reporting for any given project, including BRIC programs. Internal controls will be incorporated at the Corporation level for future grants that use an outside Grant Administrator. Anticipated Completion Date: 2/16/2026
FINDING 2025-006 Finding Subject: COVID-19 - Education Stabilization Fund - Earmarking Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding...
FINDING 2025-006 Finding Subject: COVID-19 - Education Stabilization Fund - Earmarking Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: When the current treasurer was hired, the ESSER III grant was at the end of the grant cycle. The learning loss aspect was discovered toward the end of the funding. In the future, breakdowns of grant funding will be understood by the treasurer and used as a guide for expenditures, helping the grant administrators keep on track with the grant budget. In addition, internal controls will be designed to ensure compliance with requirements of grant programs, such as a secondary review by another staff member who understands the program requirements. Anticipated Completion Date: 2/16/2026
FINDING 2025-005 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding ...
FINDING 2025-005 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Internal controls for reimbursement requests will include necessary documentation of expenditures from the accounting program attached to the reimbursement form for all grants. Each reimbursement request will be checked and approved by two school employees. The treasurer will keep the packet until funds are received and receipted and then the packet, with the receipt, will be filed in two places; the respective grant folder and in the monthly receipt folder. Anticipated Completion Date: 2/16/2026
FINDING 2025-004 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Annual Report Card, High School Graduation Rate Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@s...
FINDING 2025-004 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Annual Report Card, High School Graduation Rate Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: When removing students from the graduation cohort, files will be kept in two places. One will be a file of all transfers/removals from the cohort. That same information will be filed in each students’ file. These files will be kept at the high school. An internal control will be developed that will ensure that the proper documentation is retained. Anticipated Completion Date: 2/16/2026
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