Corrective Action Plans

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Federal Program: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing: 93.110 Federal Agency: Maternal and Child Health Federal Consolidated Programs (MCH) Grant Award Number: 5 T73MC30767-09 Award Period: 7/1/2024-6/30/2025 Management ...
Federal Program: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing: 93.110 Federal Agency: Maternal and Child Health Federal Consolidated Programs (MCH) Grant Award Number: 5 T73MC30767-09 Award Period: 7/1/2024-6/30/2025 Management agrees with the finding and has strengthened our internal controls and procedures to ensure required FFATA reports are submitted timely in compliance with the Federal Transparency Act. Paula Yarbrough, VUMC Director – Grants and Contracts will be responsible for the implementation by fiscal year-end 2026.
The agency concurs with this finding as the documents provided by the agency showed that some contracts that were modified and met the required threshold for FFATA reporting was not done when the modifications were approved. FFATA reporting has been done by the agency but a breakdown in the reportin...
The agency concurs with this finding as the documents provided by the agency showed that some contracts that were modified and met the required threshold for FFATA reporting was not done when the modifications were approved. FFATA reporting has been done by the agency but a breakdown in the reporting process by the agency did not include reporting contracts that has modification. The agency is revising internal policies and procedures to ensure all staff responsible for FFATA reporting understand that all contracts, including contracts that have modifications that increase funding up to the threshold of FFATA reporting, must be included in the FFATA reporting. Continuous training will be done for all financial staff responsible for FFATA training.
The agency concurs with this finding as subrecipient monitoring has increased significantly with increase federal funding award to the agency. Subrecipient monitoring has been in place but with new staff being hired the agency processes were not monitored and followed to ensure subrecipient monitori...
The agency concurs with this finding as subrecipient monitoring has increased significantly with increase federal funding award to the agency. Subrecipient monitoring has been in place but with new staff being hired the agency processes were not monitored and followed to ensure subrecipient monitoring requirements were completed. The agency is in the process of strengthening its policies as they are related to subrecipient monitoring. The agency is in the process of reviewing and strengthening its internal policy related to subrecipient monitoring. The agency is working with the State Controller’s Office to include subrecipient monitoring training which will take place in early 2026. The agency is implementing standardized processes to include subrecipient checklist that will be included in all agreements that will identify if the agreement is a subrecipient or contract. The agency is working to ensure all agreement templates have correct subrecipient language Per 2 CFR §200.332 prior to submission for signatures.
The agency has verified and concurs with the finding as the payroll expense was inadvertently posted to the incorrect Chartfield. The agency failed to complete the requested journal entry, which was a communication failure within the ASD division. The ASD division has corrected this issue with added...
The agency has verified and concurs with the finding as the payroll expense was inadvertently posted to the incorrect Chartfield. The agency failed to complete the requested journal entry, which was a communication failure within the ASD division. The ASD division has corrected this issue with added communication levels to ensure that more than one person received communication between ASD and agency divisions. The ASD division has implemented better communication lines between the ASD division and the agency divisions which will resolve this issue. With more than one person receiving the information and additional training on ensuring that all reconciling items are addressed timely the agency general ledger will remain clean and in balance with allowable expended posted to the correct Chatfield’s.
The Agency's management agrees with this finding. During the upcoming fiscal year, the Controller, Kimberly Houghton-Bryan, will work with various departments within the Agency including HR and ORR program directors to identify items that are direct charges or allocated based on percentages to the U...
The Agency's management agrees with this finding. During the upcoming fiscal year, the Controller, Kimberly Houghton-Bryan, will work with various departments within the Agency including HR and ORR program directors to identify items that are direct charges or allocated based on percentages to the Unaccompanied Alien Children (UAC) grant where possible. Allocation methods that are allowable under the funding sources will be reviewed for implementation. Methods, such as quarterly time studies, direct recording of time or other methods will be considered to ensure there is supporting documentation. The approved budget is also monitored on a monthly and/or quarterly basis and compared to the UAC approved budget. The allocation process as well as other accounting processes relating to New Horizons are being reviewed and the Accounting which had been outsourced is being brought internally. The Agency will be performing reviews of the internal allocation methodology, at least every other quarter-end. This enhancement will be implemented by March 31,2026. Note: Implementation of corrective action is taking place under the new Financial Controller, Kimberly Houghton-Bryan who recently acquired the role January 2026. Under her leadership, the changes she is making will be complete for Fiscal year 2026-2027 and will be a work in progress for fiscal year 2025-2026.
The Agency's management agrees with this finding and is committed to the development of a solid internal control system that will enable timely reports to government sources. The Agency under the oversight of newly hired Financial Controller Kimberly Houghton-Bryan will develop monthly and quarterly...
The Agency's management agrees with this finding and is committed to the development of a solid internal control system that will enable timely reports to government sources. The Agency under the oversight of newly hired Financial Controller Kimberly Houghton-Bryan will develop monthly and quarterly closing procedures to aid in the timely closing and filing of reports required by Assistance Listing No. 93.676. Financial Controller, Kimberly Houghton-Bryan, is to implement the checklist by March 31, 2026, to ensure that regulatory reporting is prepared in timely manner.
On November 4, 2025, UK HealthCare (UKHC) Information Technology implemented a system configuration change within Epic related to the NFV Sliding Scale settings. This change restricts the application of Federal Poverty Level (FPL) discounts to accounts with a status of “Approved for Financial Assist...
On November 4, 2025, UK HealthCare (UKHC) Information Technology implemented a system configuration change within Epic related to the NFV Sliding Scale settings. This change restricts the application of Federal Poverty Level (FPL) discounts to accounts with a status of “Approved for Financial Assistance,” thereby preventing discounts from being applied to accounts that have not been formally approved. In addition, on December 8, 2025, a new status option— “Did Not Apply for FA”—was added to the status field within the FPL table in Epic. This option is to be selected when patients do not apply for financial assistance, ensuring that status fields are never left incomplete or blank. NFVCHC staff were notified of this update and instructed to consistently complete this step. Planned Process Improvements:NFVCH leadership will conduct a comprehensive review of the NFV and JB clinic policies and procedures related to Financial Assistance Program (FAP) eligibility determination and reevaluation. This review will ensure that: FAP documentation does not include overlapping coverage periods Effective and termination dates are properly validated Internal processes align with system requirements and safeguard against data inconsistencies Ongoing Monitoring / Sustainability Plan: To strengthen oversight and ensure longterm control effectiveness, UKHC Enterprise Revenue Cycle will incorporate into its monthly audit procedures the following reviews: A report identifying accounts with blank or incomplete status entries on the Federal Poverty Level table A review of overlapping FPL coverage dates Monitoring for patients who have both UK and NFV Charity Care, ensuring the correct NFV FPL table is applied for NFVCH accounts This continuous monitoring will ensure system controls operate as designed and that corrective actions remain effective over time. Responsible Party: Larry Quillen – Executive Director, NFVCH Anne Wray - ERC Revenue Assurance Director/UKHC Target Completion Date: Completed on November 4, 2025, with additional enhancements on December 9, 2025
The untimely filing occurred due to the transition to a new staff member responsible for report submission. Management has since provided additional training, clarified filing responsibilities, and implemented supervisory review and deadline tracking to ensure reports are submitted within required t...
The untimely filing occurred due to the transition to a new staff member responsible for report submission. Management has since provided additional training, clarified filing responsibilities, and implemented supervisory review and deadline tracking to ensure reports are submitted within required timeframes going forward.
Brooklyn Law School Single Audit Corrective Action Plan For the Year Ending June 30, 2025 Section III - Federal Awards Findings and Questioned Costs Finding 2025-001: Significant Deficiency - NSLDS Enrollment Reporting Criteria: Title IV regulations (34 CFR 685.309(b)) require that upon receipt of a...
Brooklyn Law School Single Audit Corrective Action Plan For the Year Ending June 30, 2025 Section III - Federal Awards Findings and Questioned Costs Finding 2025-001: Significant Deficiency - NSLDS Enrollment Reporting Criteria: Title IV regulations (34 CFR 685.309(b)) require that upon receipt of an enrollment report from the Secretary of the Department of Education (Secretary), institutions must update all information included in the report and return the report to the Secretary: (I) in the manner and format prescribed by the Secretary; and (ii) within the timeframe prescribed by the Secretary. Unless the institution expects to submit its next updated enrollment report to the Secretary within the next 60 days, an institution must notify the Secretary within 30 days after the date the institution discovers that: (i) a loan under Title IV of the Act was made to or on behalf of a student who was enrolled or accepted for enrollment at the institution, and the student has ceased to be enrolled on at least a halftime basis or failed to enroll on at least a half-time basis for the period for which the loan was intended or (ii) a student who is enrolled at the institution and who received a loan under Title IV of the Act has changed his or her permanent address. Condition: The Law School did not notify the National Student Loan Data System (NSLDS) in a timely manner for 23 students with status changes in our sample of 25 students. For 2 out of 25 students selected in the sample, the effective date that was reported to the NSLDS did not match the date that the student changed status. The sample was not a statistically valid sample. Questioned Costs: There are no questioned costs associated with this finding. Cause: The Law School's controls surrounding the reporting of students’ statuses and status effective dates to the NSLDS did not appropriately ensure the information was submitted accurately or timely. Effect: The accuracy of the Title IV student loan records depends heavily on the accuracy of the enrollment information reported by schools. If an institution does not review, update, and verify student enrollment statuses, effective dates of the enrollment status, and the anticipated completion dates, then the Title IV student loan records will be inaccurate. Recommendation: We recommend that the Law School review its procedures for student status changes and NSLDS notifications to ensure there are follow-up and review procedures being performed for all students with status changes at the Law School to ensure accurate and timely reporting. Management Response: Management agrees with the finding, The Director of Financial Aid and the Registrar will implement procedures and controls in fiscal 2026 to ensure accurate and timely updating of the enrollment reports to NSLDS. Anticipated Completion Date: June 30, 2026 Responsible Person: John K. Zhang, Vice President for Finance and Board Treasurer (718)-780-7503 - john.zhang@brooklaw.edu
The District will review federal procurement requirements to ensure proper compliance.
The District will review federal procurement requirements to ensure proper compliance.
Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement formal policies and procedures requiring remittance of federal funds directly to subrecipients, rather than paying vendors on the sub...
Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement formal policies and procedures requiring remittance of federal funds directly to subrecipients, rather than paying vendors on the subrecipient's behalf. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective October 1, 2025, all subrecipients were notified that payments would be made only to them, requiring them to directly pay their contractors and vendors. Name(s) of the contact person(s) responsible for corrective action: Lee McKenzie, OARN Grant Manager Planned completion date for corrective action plan: October 1, 2025
Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement formal policies and procedures requiring timesheets and payroll registers to be reviewed and approved, with such review and approval ...
Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement formal policies and procedures requiring timesheets and payroll registers to be reviewed and approved, with such review and approval clearly documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective January 1, 2026, the process for timesheet review has been updated. Previously, preliminary timesheets were reviewed and approved before payroll was entered into the system. Now, all final timesheets will be reviewed, approved, and cross-referenced with payroll registers to ensure consistency. Any identified errors will be documented and promptly resolved. Name(s) of the contact person(s) responsible for corrective action: Kendra Jones Planned completion date for corrective action plan: January 1, 2026
Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement formal policies and procedures requiring the tracking and submission of performance reports within the required timeframe. Explanatio...
Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement formal policies and procedures requiring the tracking and submission of performance reports within the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The late submission of OARN's Semi-Annual Progress Reports is directly related to the current EHB report format. This format is challenging because it requires specific, unique answers for each of our 19 sites but only provides fields for 10. This limitation makes accurate and comprehensive reporting impossible, as the correct response is unique to each site. While we have collaborated with EHB to modify the format, the submission is still restricted to 10 sites. Consequently, for the most recent reporting period, we completed the electronic submission for the initial 10 sites and submitted a separate emailed document containing the progress information for the remaining 9 sites. Moving forward, until the report format is permanently changed, we plan to continue using this two-part submission strategy to ensure timely reporting. Name(s) of the contact person(s) responsible for corrective action: Lee McKenzie, OARN Grant Manager Planned completion date for corrective action plan: April 30, 2026
Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement formal policies and procedures requiring the review and approval of performance, with such review and approval clearly documented. Ex...
Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement formal policies and procedures requiring the review and approval of performance, with such review and approval clearly documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective January 1, 2026, the Executive Director will review a PDF copy and document approval via email of OARN's Semi-Annual Progress Reports prior to uploading into the EHB. Name(s) of the contact person(s) responsible for corrective action: Kendra Jones, Executive Director Planned completion date for corrective action plan: January 1, 2026
Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement formal policies and procedures requiring timesheets to be reviewed and approved, with such review and approval clearly documented. Ex...
Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement formal policies and procedures requiring timesheets to be reviewed and approved, with such review and approval clearly documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Previously, preliminary timesheets were reviewed and approved before payroll entry, but a signature was not required. The timesheet review process has been updated, effective January 1, 2026. Now, both preliminary and final timesheets require the following steps: 1. Review 2. Approval 3. Signature 4. Conversion to PDF (to prevent alteration). Name(s) of the contact person(s) responsible for corrective action: Kendra Jones, Executive Director Planned completion date for corrective action plan: January 1, 2026
Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend the Association design controls to ensure an adequate review process is in place to review potential subrecipients, contractors, or vendors to determine they are no...
Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend the Association design controls to ensure an adequate review process is in place to review potential subrecipients, contractors, or vendors to determine they are not suspended or debarred prior to entering into transactions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: OARN's vendor approval process has included the following steps:● Review and Verification: Review the Vendor Approval Form to ensure it is complete and includes all necessary documentation. Verify that the vendor is not excluded from receiving federal contracts by checking for debarment on SAM.gov. ● Decision: Approve or deny the Approval Form. ● Communication and Record-Keeping: Return a signed and dated copy to the vendor, indicating approval or denial. Enter information for all approved vendors into the grant management tracking system. OARN recognizes that an essential best practice for federal compliance is conducting semi-annual checks on SAM.gov to confirm a vendor's continued eligibility for federal funds. Effective January 1, 2026, OARN implemented a policy to review all vendors' status on SAM.gov. This initial review is scheduled for completion by February 28, 2026. A subsequent review will take place in July 2026 for any vendors involved in projects that are still ongoing. Name(s) of the contact person(s) responsible for corrective action: Lee McKenzie, OARN Grant Manager Planned completion date for corrective action plan: February 28, 2026
Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement policies and procedures to ensure the performance of subrecipient monitoring and that the monitoring is formally documented and appro...
Community Project Funding/Congressionally Directed Spending ‐ Construction – Assistance Listing No. 93.493 Recommendation: We recommend that the Association implement policies and procedures to ensure the performance of subrecipient monitoring and that the monitoring is formally documented and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: OARN's current monitoring of Subrecipients has included reviewing budgets and progress reports, approving vendors, and processing drawdown requests to confirm the appropriate use of subaward funds in compliance with Federal regulations and subaward terms. However, OARN recognizes the need for a more comprehensive review process to ensure full subrecipient compliance. Therefore, we plan to request audits or financial reviews from all subrecipients. We will also require documentation demonstrating that the subrecipient has taken prompt and necessary corrective action in response to any deficiencies identified through audits, on-site reviews, or other methods related to the Federal program. OARN has created and will maintain a Subrecipient Monitoring and Approval Form that tracks receipt and review of 1) audit reports and corrective actions along with 2) checks on SAM.gov to confirm the subrecipient's continued eligibility for federal funds. Name(s) of the contact person(s) responsible for corrective action: Lee McKenzie, OARN Grant Manager Planned completion date for corrective action plan: March 30, 2026
Management Response and Planned Corrective Plan: HUD approved a withdrawal of $4,279 from the reserve replacement account. The $4,279 was mistakenly withdrawn twice and has been refunded to the reserve replacement account.
Management Response and Planned Corrective Plan: HUD approved a withdrawal of $4,279 from the reserve replacement account. The $4,279 was mistakenly withdrawn twice and has been refunded to the reserve replacement account.
The Controller shall conduct a thorough review of all grants awarded during the Fiscal Year to determine the funding source of the grant (Federal, State, Local, or private) by researching grant documents, memorandums, program profiles, appropriation acts, and information obtained from government age...
The Controller shall conduct a thorough review of all grants awarded during the Fiscal Year to determine the funding source of the grant (Federal, State, Local, or private) by researching grant documents, memorandums, program profiles, appropriation acts, and information obtained from government agency Web sites. The Controller shall add new grants received to the Schedule of Expenditures of Federal and State Awards based on findings from the review.
The Village has discussed the finding but must consider the cost of adequate segregation of duties when determining the use of tax money.
The Village has discussed the finding but must consider the cost of adequate segregation of duties when determining the use of tax money.
Views of responsible officials and corrective action: The organization hired an individual contractor to assist with the implementation of a formal financial closing process, which includes identifying a detailed and specific process to review and reconcile procedures to ensure accurate reporting of...
Views of responsible officials and corrective action: The organization hired an individual contractor to assist with the implementation of a formal financial closing process, which includes identifying a detailed and specific process to review and reconcile procedures to ensure accurate reporting of federal expenditures and alignment with the general ledger. Responsible Individual: Okeema Polite, CEO/Executive Director Todd Falcone, Independent Contractor Bookkeeper Vannessa Lindsey, Board President Implementation Date: ACAC has begun implementing the procedures with the assignment to the Independent Contractor as of May 2025. Recommended procedures will be implemented by July 30, 2026
Finding 2025-002: Internal Controls over Compliance Responsible Individuals: Mark Miller, Accounting Manager Corrective Action Plan: Management is currently implementing review procedures and proper oversight of compliance. Anticipated Completion Date: 2026
Finding 2025-002: Internal Controls over Compliance Responsible Individuals: Mark Miller, Accounting Manager Corrective Action Plan: Management is currently implementing review procedures and proper oversight of compliance. Anticipated Completion Date: 2026
Finding 2025-001 The College concurs with the audit finding that students who withdrew at the conclusion of the fall 2024 semester were not reported to the National Student Loan Data System (NSLDS) within the required 60-day reporting timeframe. This occurred as a result of two primary factors: (1) ...
Finding 2025-001 The College concurs with the audit finding that students who withdrew at the conclusion of the fall 2024 semester were not reported to the National Student Loan Data System (NSLDS) within the required 60-day reporting timeframe. This occurred as a result of two primary factors: (1) the enrollment reporting schedule with the National Student Clearinghouse was outdated, and (2) the 60-day reporting requirement was not clearly defined within Allegheny’s internal processes. Allegheny recognizes the importance of timely and accurate reporting of students’ enrollment status to NSLDS. Enrollment rosters and updated enrollment statuses are regularly reported to NSLDS to ensure that changes affecting loan repayment obligations and in-school deferment eligibility are accurately reflected within the Department of Education’s records. The College is committed to strengthening its procedures to ensure continued compliance with federal reporting requirements. The College will continue to adhere to NSLDS reporting processes and required timelines. Through enhanced collaboration among the Financial Aid, Registrar’s, and Provost’s Offices, Allegheny will fully align and formalize enrollment reporting procedures. The College will review, verify, and update reporting schedules to ensure accuracy and compliance with applicable requirements. Specifically, the College will annually review its enrollment reporting schedule with the National Student Clearinghouse to ensure that enrollment data is transmitted to the National Student Loan Data System (NSLDS) at least once every 60 calendar days, in accordance with federal reporting requirements. For students who notify the College of their intent to leave at the upcoming conclusion of a semester, the College will report the student as enrolled on the final enrollment report for that term and will then manually update the student's enrollment status to withdrawn within a few days of the report’s submission, rather than waiting for the next scheduled enrollment transmission, to ensure timely and accurate reporting. Allegheny College will implement quarterly review of processes established to ensure compliance. This proactive approach will ensure ongoing compliance with federal regulations. In addition, Allegheny College is developing a secondary review process for each enrollment report submission to identify students with recent or pending enrollment status changes. This review will serve as a quality control check to ensure that students whose enrollment status has changed since the prior reporting period are accurately identified and updated, thereby strengthening oversight and ensuring timely and compliant reporting to NSLDS.
Background During the audit, it was identified that the University did not report all required program-level record elements to the National Student Loan Data System (NSLDS). Cause The root cause of the issue was a gap in our data entry and reporting processes: • Prior to January 1 2025, majors and ...
Background During the audit, it was identified that the University did not report all required program-level record elements to the National Student Loan Data System (NSLDS). Cause The root cause of the issue was a gap in our data entry and reporting processes: • Prior to January 1 2025, majors and program-level data for domestic students were entered by the domestic enrollment team. With the transition of responsibilities to the Registrar’s Office, controls were fully aligned to ensure program-level elements were consistently captured and transmitted. Corrective Action Plan The University has taken and will continue to take the following corrective actions: 1. Process Realignment o Responsibility for capturing and validating program-level record elements has been formally assigned to the Registrar’s Office. 2. System Enhancements o Validation reports have been developed to flag missing or inconsistent program-level data prior to NSLDS submission. 3. Follow-Up Monitoring o Quarterly monitoring ensures proactive identification and correction of any missing program-level enrollment data prior to submitting data to NSLDS. Conclusion The University is committed to ensuring full compliance with NSLDS enrollment reporting requirements. We believe the corrective measures outlined above will prevent recurrence of incomplete program-level reporting and strengthen the reliability of our enrollment submissions. Sincerely, Christopher Bryan CFO
Corrective Action Plan Finding 2025-001 Condition: A journal entry was tested during the compliance audit that reclassified $50,000 of employee health costs to the school lunch fund that did not include any documentation of the costs charged to the school lunch fund and how they were allocated. Corr...
Corrective Action Plan Finding 2025-001 Condition: A journal entry was tested during the compliance audit that reclassified $50,000 of employee health costs to the school lunch fund that did not include any documentation of the costs charged to the school lunch fund and how they were allocated. Corrective Action Planned: Effective July 1, 2025, the District began to implement a structured and documented cost allocation process for employee healthcare expenses attributable to the Food Services Department. Beginning in FY26: • Charges will be processed monthly to ensure transparency, consistency, and proper budget tracking. Anticipated Completion Date: Ongoing Contact: Richard Poor, Director of Finance & Operations
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