Corrective Action Plans

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The Colorado Department of Transportation (CDOT) agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated on its implementation. The Department has assessed and updated training for staff responsible for reviewing and approving in...
The Colorado Department of Transportation (CDOT) agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated on its implementation. The Department has assessed and updated training for staff responsible for reviewing and approving invoices for Highway Safety Cluster grants, with a specific focus on the period of performance. This training plan will be revisited and reviewed with all staff involved by April 2026.
The Department agrees with the recommendation. The Department will review, assess, and, where necessary, update existing procedures for FFATA reporting relating to the requirement that state subawards for $30,000+ be submitted within 30 days of committed budget. This will include ensuring that the c...
The Department agrees with the recommendation. The Department will review, assess, and, where necessary, update existing procedures for FFATA reporting relating to the requirement that state subawards for $30,000+ be submitted within 30 days of committed budget. This will include ensuring that the confirmation date is documented. This process will be a coordinated effort between the Office Transportation Safety (OTS) and the Center for Accounting. This will include updating our reconciliation process to include additional data, reviewing and updating reconciliation and review procedures as needed, and reconciling Grants awarded in prior fiscal years that are still active and ensuring they have been appropriately reported. The findings related to this recommendation are in part the result of a federal reporting system limitation, and a federal system conversion. The legacy reporting system, FSRS, had a system limitation, which prevented the full amount of the award being reported in the case of three awards. Additionally, this conversion resulted in some data conversion issues impacting one additional award.
The Department agrees with this finding and will provide any training needed to staff members to ensure that all components of the FFATA are completed accurately, timely and with proper reviews. This training will include leadership reviewing NHTSA/Federal guidelines and SAM.Gov training on FFATA re...
The Department agrees with this finding and will provide any training needed to staff members to ensure that all components of the FFATA are completed accurately, timely and with proper reviews. This training will include leadership reviewing NHTSA/Federal guidelines and SAM.Gov training on FFATA reporting and requirements, documenting controls and ensuring the approvers have access to all supporting schedules, forms and systems and that they understand the subawards, and process for late submissions if needed.
The Department agrees with the finding and will ensure that staff follow all internal policies and procedures to maintain accurate and complete FFATA reporting. To achieve this, staff will review existing procedures and make any necessary updates regarding report compilation. Additionally, we will r...
The Department agrees with the finding and will ensure that staff follow all internal policies and procedures to maintain accurate and complete FFATA reporting. To achieve this, staff will review existing procedures and make any necessary updates regarding report compilation. Additionally, we will review control points to ensure they are consistently followed and approved by the team supervisor and team manager.
The Department will continue to follow the current Policy and Procedure related to the Single Audit reviews and has allocated an individual to review the Single Audits. This includes issuing a management decision letter if required, in accordance with the timeline established in federal guidance.
The Department will continue to follow the current Policy and Procedure related to the Single Audit reviews and has allocated an individual to review the Single Audits. This includes issuing a management decision letter if required, in accordance with the timeline established in federal guidance.
CDPHE fiscal procedures have been updated to reflect changes to the reporting process, specifically noting the recent federal website change and adding the requirement of a secondary level of review. By July 31, 2026, all outstanding FFATA reports will be filed with the federal government and the mo...
CDPHE fiscal procedures have been updated to reflect changes to the reporting process, specifically noting the recent federal website change and adding the requirement of a secondary level of review. By July 31, 2026, all outstanding FFATA reports will be filed with the federal government and the monthly review process in the updated fiscal procedures will be implemented.
The Department of Local Affairs (Department) agrees with the recommendation to strengthen internal controls over the financial management of federal Coronavirus Capital Projects Fund grant expenditures and the accuracy and completeness of the Exhibit K1, Schedule of Federal Assistance. The Departmen...
The Department of Local Affairs (Department) agrees with the recommendation to strengthen internal controls over the financial management of federal Coronavirus Capital Projects Fund grant expenditures and the accuracy and completeness of the Exhibit K1, Schedule of Federal Assistance. The Department will develop a corrective action plan that includes enhanced procedures for the performance of year-end estimates/accruals. The Department will create and implement staff training for staff that are responsible for preparing and reviewing the estimates/accruals, the Exhibit K1, grant transactions and enhancements.
The Department will strengthen its internal controls over federal reporting by implementing policies and procedures that include a monitoring process to ensure that FFATA reporting occurs as required for subawards of $30,000 or more in SAM.gov by the end of the month following the month the subaward...
The Department will strengthen its internal controls over federal reporting by implementing policies and procedures that include a monitoring process to ensure that FFATA reporting occurs as required for subawards of $30,000 or more in SAM.gov by the end of the month following the month the subawards are made.
The Department will document and implement internal monitoring policies and procedures, including the performance of reconciliations of reports, to ensure that the required PR28 and Quarterly Performance Reports are accurate and complete. This will include maintaining documentation of evidence of th...
The Department will document and implement internal monitoring policies and procedures, including the performance of reconciliations of reports, to ensure that the required PR28 and Quarterly Performance Reports are accurate and complete. This will include maintaining documentation of evidence of the review and approval of each report prior to its submission to the federal government.
The Department will complete and communicate formalized IT procedures to staff and IT service providers for IT general control activities for MyUI+ by April 2026.
The Department will complete and communicate formalized IT procedures to staff and IT service providers for IT general control activities for MyUI+ by April 2026.
The Department will implement Part B of the confidential finding.
The Department will implement Part B of the confidential finding.
The Department will implement Part A of the confidential finding.
The Department will implement Part A of the confidential finding.
The Department will implement Part B of the confidential finding.
The Department will implement Part B of the confidential finding.
MSU Denver manages enrollment reporting within the Office of the Registrar. We develop a schedule each calendar year and semester with NSC to identify scheduled reporting dates for each term in alignment with critical semester dates (start, end, drop, etc.). In Fiscal Year 2025, there was a technica...
MSU Denver manages enrollment reporting within the Office of the Registrar. We develop a schedule each calendar year and semester with NSC to identify scheduled reporting dates for each term in alignment with critical semester dates (start, end, drop, etc.). In Fiscal Year 2025, there was a technical issue in which we had to work with our ERP vendor, Ellucian, to provide a solution. The Office of the Registrar will strengthen its internal controls to ensure enrollment changes are reported within the required 60-day timeline.
MSU Denver IT Security will update its written information security program to address the necessary requirements of the Gramm-Leach-Bliley Act. The WISP will be reviewed and updated at least once each year, with updates being based on risk assessments, audits, changes to the environment, and any in...
MSU Denver IT Security will update its written information security program to address the necessary requirements of the Gramm-Leach-Bliley Act. The WISP will be reviewed and updated at least once each year, with updates being based on risk assessments, audits, changes to the environment, and any incidents which indicate a need for changes to the WISP. The updated WISP will include existing policies as well as new policies that describe standards for: • Periodic inventory of data • Multi-Factor Authentication, Single Sign-On, and passwords • Assessment of applications developed by the institution • Testing our safeguards The updated WISP will be formally reviewed and approved by the Chief Financial Officer by June 30, 2026.
The Colorado State University and Colorado State University – Pueblo campuses will strengthen their internal controls to ensure enrollment changes are reported within the required 60-day timeline for newly enrolled students. Additionally, the Colorado State University and Colorado State University –...
The Colorado State University and Colorado State University – Pueblo campuses will strengthen their internal controls to ensure enrollment changes are reported within the required 60-day timeline for newly enrolled students. Additionally, the Colorado State University and Colorado State University – Pueblo campuses will improve the documentation provided as part of compliance testing as both students referenced within the finding were unique situations. In both instances referenced, additional context was not provided during compliance testing for both students that was not captured on the provided National Student Loan Data System Campus Enrollment Details webpage that showed the appearance of reporting an enrollment status change outside of the 60-day requirement. For the Colorado State University, the student was reported with an effective date of the beginning of the Fall 2024 Semester but did not complete verification procedures until February 2025 and was then disbursed the Fall 2024 portion of their Pell Grant. For Colorado State University – Pueblo, the student was reported with an effective date of the beginning of the Fall 2024 Semester, but corrections were required on the student’s FAFSA before federal student financial aid could be disbursed. The campuses will improve documentation provided during compliance testing for when these unique situations with enrollment reporting occur.
The Department agrees to strengthen its internal controls over Medicaid eligibility to ensure compliance with federal and state regulations. Colorado will continue its approved Centers for Medicare and Medicaid mitigation plan to ensure that eligibility is determined on an individual rather than a h...
The Department agrees to strengthen its internal controls over Medicaid eligibility to ensure compliance with federal and state regulations. Colorado will continue its approved Centers for Medicare and Medicaid mitigation plan to ensure that eligibility is determined on an individual rather than a household basis. The Department will continue to conduct ex parte reviews to determine eligibility for all household members based on available information. Those members identified as eligible at ex parte will be approved, regardless if others in the household continue to need verifications or are no longer eligible. The Department is currently working on a permanent system change for CBMS that will only send out renewal forms for individuals not eligible through the ex parte process, with implementation by December 2026.
The Department of Health Care Policy and Financing has examined rate maintenance practices since FY2024 to determine the best course of action to strengthen internal controls to subsequently develop formal policies and procedures. The Waiver and Fee Schedule Rates section will develop a formal, reco...
The Department of Health Care Policy and Financing has examined rate maintenance practices since FY2024 to determine the best course of action to strengthen internal controls to subsequently develop formal policies and procedures. The Waiver and Fee Schedule Rates section will develop a formal, recorded training and corresponding training materials based on current, informal processes on completion of the rate update form to be submitted to the Department's fiscal agent, Gainwell Technologies. Since FY2024, the Waiver and Fee Schedule Rates section has implemented a multilevel secondary review process prior to any rate change submission to ensure accuracy in rate update submissions. The Rates section has also worked closely with other internal partners to formalize informal update processes for quality assurance and maintenance of a minimal error percentage. The Rates section has also implemented a post-implementation data analysis review of all rate update submissions to ensure the update was implemented as directed and expected to ensure accountability on behalf of the Department's fiscal agent Gainwell Technologies. The Rates section is currently in process of documenting and formalizing all rate update processes and policies for future training and process maintenance.
The Department agrees with the recommendation and will strengthen internal controls over Children’s Basic Health Plan eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring ...
The Department agrees with the recommendation and will strengthen internal controls over Children’s Basic Health Plan eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring Department-approved Corrective Action Plans. These plans will be required to address root causes related to income documentation, application of correct income thresholds, and compliance with CBHP eligibility requirements, including any necessary training or guidance for county and Medical Assistance site caseworkers. The Department will review, approve, and monitor corrective actions to ensure deficiencies are addressed.
The Department agrees with the recommendation and will strengthen internal controls over Medicaid eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring the development and ...
The Department agrees with the recommendation and will strengthen internal controls over Medicaid eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring the development and implementation of Department-approved Corrective Action Plans. These plans will be required to address root causes related to income and resource calculation, documentation of eligibility determinations, and household composition, including any necessary training or guidance for county and Medical Assistance site caseworkers. The Department will review, approve, and monitor corrective actions to ensure deficiencies are appropriately addressed.
Subject: Corrective Action Plan for Federal Direct Student Loans Program Compliance The University of the Pacific acknowledges the findings outlined in the audit related to the reporting of student enrollment status to the National Student Loan Data System (NSLDS) for the Federal Direct Student Loan...
Subject: Corrective Action Plan for Federal Direct Student Loans Program Compliance The University of the Pacific acknowledges the findings outlined in the audit related to the reporting of student enrollment status to the National Student Loan Data System (NSLDS) for the Federal Direct Student Loans Program (Federal Assistance Listing Number: 84.268) for the award year July 1, 2024 – June 30, 2025. The audit identified a system-level transmittal configuration issue in which campus-level enrollment updates inadvertently overrode certain program-level enrollment status fields within NSLDS reporting. We take our responsibility to comply with the federal regulations under 34 CFR Section 685.309 very seriously and are committed to strengthening our internal controls and system governance processes to ensure accurate, complete, and timely reporting of enrollment changes at both the campus and program levels. Corrective Action Plan: To address the identified deficiency, Finding# 2025-001, related to program-level enrollment status reporting and to strengthen preventive controls over NSLDS submissions, the University has implemented the following measures, effective immediately (February 19, 2026): 1. Root Cause Isolation and System Logic Review: The University identified that a specific NSLDS transmittal file configuration resulted in campuslevel enrollment updates overriding program-level enrollment status fields. In collaboration with Information Technology, the Registrar’s Office has isolated the reporting logic and corrected the configuration to prevent program-level status fields from being overwritten by subsequent campus-level submissions. Documentation of the revised logic has been retained for audit purposes. 2. Full Population Review and Remediation: The University will conduct a comprehensive review of NSLDS records for the affected student population to confirm accuracy of program-level enrollment status. Where discrepancies are identified, corrected submissions will be transmitted promptly to NSLDS. Documentation of the review and any corrections will be maintained to ensure a complete audit trail. 3. Segregation of Campus-Level and Program-Level Reporting Logic: Enrollment reporting procedures have been updated to formally distinguish campus-level and program-level reporting workflows. Any future modifications to enrollment reporting logic will require documented change management review, regression testing, and joint approval from the Registrar’s Office and Information Technology prior to implementation. 4. Targeted Program-Level Monitoring Dashboard: In addition to existing monthly NSC and NSLDS reconciliations, the Registrar’s Office will implement a targeted monthly exception report specifically monitoring program-level enrollment status changes. This report will identify discrepancies between SIS records and transmitted data, including concurrent program records and recent status changes, to ensure ongoing data integrity. 5. Quarterly Compliance Sampling and Oversight: On a quarterly basis, an independent staff member not involved in file preparation will conduct a sampling review of transmitted NSLDS records to verify program-level status accuracy. Results will be documented and reviewed by the Registrar to ensure sustained compliance. 6. SOP Enhancement and Staff Training: The University has updated its Enrollment Reporting Standard Operating Procedures to incorporate explicit review steps for program-level data validation and transmission oversight. Targeted training has been provided to staff responsible for enrollment reporting to reinforce compliance expectations and system configuration awareness. The University remains committed to ensuring accurate and timely reporting of student enrollment data in full compliance with federal regulations. These enhanced preventive and governance controls build upon prior corrective actions and further strengthen the integrity of our Title IV reporting framework. Anticipated Completion Date: 6/30/26 Person Responsible: Michael Snyder, Associate University Registrar
The Council is award of the requirements concerning advances from the Payment Management System and plan to establish internal controls concerning such advances in the future.
The Council is award of the requirements concerning advances from the Payment Management System and plan to establish internal controls concerning such advances in the future.
Management has put procedures in place in the current year to ensure timely submission.
Management has put procedures in place in the current year to ensure timely submission.
The Medical Center will create calendar appointments prior to required deadline for submission of the audited financial statements and annual budget for the responsible personnel including the chief financial officer.
The Medical Center will create calendar appointments prior to required deadline for submission of the audited financial statements and annual budget for the responsible personnel including the chief financial officer.
Re: Finding 2025 001 – Significant Deficiency in Internal Control Over Financial Reporting – Preparation of the Schedule of Expenditures of Federal Awards (SEFA) The Corporation agrees with the recommendation. Management acknowledges that certain federal expenditures were not initially reported on t...
Re: Finding 2025 001 – Significant Deficiency in Internal Control Over Financial Reporting – Preparation of the Schedule of Expenditures of Federal Awards (SEFA) The Corporation agrees with the recommendation. Management acknowledges that certain federal expenditures were not initially reported on the Schedule of Expenditures of Federal Awards (SEFA) in the appropriate fiscal periods due to a misunderstanding of applicable Uniform Guidance requirements and reliance on prior audit treatment. Specifically, expenditures related to Federal Emergency Management Agency (FEMA) programs were not included on the SEFA until reimbursement was received, and certain per patient payments associated with federally funded research were not initially identified as SEFA reportable. To address this matter and strengthen internal controls over the preparation and review of the SEFA, management will implement the following corrective actions: • Future FEMA expenditures will be reported on the SEFA in the fiscal year in which the projects are obligated and eligible expenditures are incurred, regardless of the timing of reimbursement. • Per patient payments received in connection with federally funded research programs will be evaluated for SEFA reporting and included as required. • A formal Standard Operating Procedures related to the preparation of the SEFA will be developed and implemented to clarify reporting requirements for obligated expenditures, per patient grant activity, and other federal awards. • Review procedures will be enhanced to include confirmation by entity and corporate leadership that all federal awards and related expenditures have been identified, evaluated, and appropriately reported on the SEFA. • Management will evaluate opportunities to complete SEFA preparation and preliminary review earlier in the audit cycle to allow for timely identification and resolution of potential reporting issues. Management believes these actions will improve the accuracy and completeness of the SEFA and reduce the risk of similar issues in future reporting periods.
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