Corrective Action Plans

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Finding Number: 2025-004 It is recommended that that district review the design of its internal control over compliance to ensure the documentation requirements are incorporated into the control design. Response: To enhance internal controls to ensure the segregation of duties, the Assistant Directo...
Finding Number: 2025-004 It is recommended that that district review the design of its internal control over compliance to ensure the documentation requirements are incorporated into the control design. Response: To enhance internal controls to ensure the segregation of duties, the Assistant Director of Food Services will be responsible for the initial preparation and completion of all the claims. Subsequently, a secondary review and approvable will be preformed by either the Director or the Chief School Business Official (CSBO) prior to submission.
Management should implement additional review controls over restricted cash that are sufficient to ensure deposits for replacement reserve are deposited in the appropriate amount.
Management should implement additional review controls over restricted cash that are sufficient to ensure deposits for replacement reserve are deposited in the appropriate amount.
Management agrees with the above finding and has implemented a plan to reduce expenses and increase cash flows going forward. Specifically, we have outlined the following steps that we are taking as an organization to get back on track:  Cash flow is monitored weekly and forecasted on a rolling 12-...
Management agrees with the above finding and has implemented a plan to reduce expenses and increase cash flows going forward. Specifically, we have outlined the following steps that we are taking as an organization to get back on track:  Cash flow is monitored weekly and forecasted on a rolling 12-week basis.  Existing vendor contracts were reviewed and changes made to reduce expenses moving forward into the 2026 fiscal year. Contracts are continually evaluated and renegotiated, where possible, for potential cost savings.  We implemented a robust and detailed budget development process to continue cost-cutting measures into 2026 and beyond. Directors are accountable to their budget guidelines to ensure expenses are appropriately managed.  The 36-unit Independent Living expansion project remains a high priority. The model home construction was completed in November 2025, with showings and open houses now underway. New homes are expected to commence construction in 2026. The sale and occupancy of these units are expected to generate substantial future cash flows for the organization.  We continue to prioritize aggressive staff recruitment to eliminate agency staffing needs. The steady decline in contract staff utilization continued in 2025, with a decrease in contract nursing costs of $317,000 or 15.6% compared to prior year. It is our goal to fully eliminate agency staffing in 2026. Rising labor costs continue to challenge cost savings measures; however, the organization is committed to managing labor costs appropriately and reducing expenses where possible. For example, in 2026, incentive bonuses for nursing shift pick-ups have been eliminated.  Management enacted a progressive plan to increase census in each of its business lines to increase revenue through focused marketing efforts and referral partnerships. Average daily census improved from 133 beds or 79% occupancy in 2024 to 145 beds or 92% occupancy in 2025. Looking ahead to 2026, the organization is focusing its efforts on achieving a more favorable skilled nursing payer mix while maintaining a strong occupancy.
Corrective Action Plan Finding 2025-001 Information on the federal program: Federal Program Name: Congressional Directives Federal Agency: U.S. Department of Health and Human Services Federal Assistant Listing and Title Number: 93.493 Award Year: September 1, 2024 to August 31, 2025 Criteria or Spec...
Corrective Action Plan Finding 2025-001 Information on the federal program: Federal Program Name: Congressional Directives Federal Agency: U.S. Department of Health and Human Services Federal Assistant Listing and Title Number: 93.493 Award Year: September 1, 2024 to August 31, 2025 Criteria or Specific Requirement: Procurement, Suspension and Debarment Condition: The District is required to have procedures to ensure vendors are not suspended or debarred prior to charging services to the grant, as well as required to follow their own documented procurement procedures which should conform to the Uniform Guidance procurement standards. Correction Action Planned: The District has reviewed the applicable requirements of the Office of Management and Budget Uniform Guidance for procurement standards, specifically those related to the requirement for procedures to be documented regarding suspension and debarment and noncompetitive procurement. The District acknowledges that their procurement policy does not currently conform to the Uniform Guidance procurement standards, and formal procurement methods were not utilized for certain grant expenses. At the time of procurement, the District operated under the understanding that engagement of a vendor holding a General Services Administration (GSA) contract was consistent with and would satisfy applicable procurement requirements. Upon further review, the District recognizes that this assumption did not, in itself, meet all Uniform Guidance requirements, particularly with respect to documentation and justification of procurement methods. To ensure compliance with Uniform Guidance going forward, the District will implement corrective actions. The District will update the current procurement policy to ensure compliance Uniform Guidance. The District will provide formal training to existing grant Program Managers on Uniform Guidance procurement standards. Additionally, for any new grant opportunities, the grant committee will receive training on Uniform Guidance procurement standards prior to the completion of grant applications. For both existing and future grants, any proposed contracts or purchases exceeding $3,000 will be subject to review by the grant Program Manager (or the Grant Committee lead, if a Program Manager has not yet been assigned) to ensure that the appropriate procurement method is utilized, all required documentation is obtained and retained, and compliance with all applicable procurement standards is verified prior to purchase or execution of any contract. Contact Person (s) Responsible for Corrective Action: Ana Zavala, Chief Financial Officer Anticipated Completion Date: These corrective actions will be implemented immediately, with training completed by May 2026.
Recommendation: Management should implement procedures to ensure HUD-approved rent increases are recorded in a timely manner, accurately applied, and supported by proper documentation. Action Taken: Housing staff and management have been informed of the required processes and documentation for reque...
Recommendation: Management should implement procedures to ensure HUD-approved rent increases are recorded in a timely manner, accurately applied, and supported by proper documentation. Action Taken: Housing staff and management have been informed of the required processes and documentation for requesting and implementing rent increases. Going forward, staff will ensure all completed and HUD-approved documentation is communicated to and reviewed with supervisors to confirm accurancy and compliance.
Recommendation: We recommend that management strengthen internal
Recommendation: We recommend that management strengthen internal
controls over the public housing inspection process by evaluating the
controls over the public housing inspection process by evaluating the
effectiveness of its current third-party inspection services. If the
effectiveness of its current third-party inspection services. If the
contractor is unable to consistently perform required annual
contractor is unable to consistently perform required annual
inspections in accordance with HUD requirements, management
inspections in accordance with HUD requirements, management
should consider discontinuing the current contract and engaging a
should consider discontinuing the current contract and engaging a
qualified, reputable inspection company. In addition, management
qualified, reputable inspection company. In addition, management
should enhance oversight procedures to monitor contractor
should enhance oversight procedures to monitor contractor
performance and ensure inspection results are reviewed,
performance and ensure inspection results are reviewed,
and corrective actions are completed, consistent with the internal
and corrective actions are completed, consistent with the internal
control standards outlined in 2 CFR 200.303.
control standards outlined in 2 CFR 200.303.
Corrective Action Plan – Material Weakness & Material Noncompliance (Single Audit) Entity Name: Froedtert ThedaCare Health (FTCH) Corrective Action Plan For the Fiscal Year Ended June 30, 2025 Finding 2025-001 – Material Noncompliance (Major Federal Program) Federal Program U.S. Department of Health...
Corrective Action Plan – Material Weakness & Material Noncompliance (Single Audit) Entity Name: Froedtert ThedaCare Health (FTCH) Corrective Action Plan For the Fiscal Year Ended June 30, 2025 Finding 2025-001 – Material Noncompliance (Major Federal Program) Federal Program U.S. Department of Health and Human Services – National Institutes of Health (NIH) – Cancer Control ALN: 93.399 Finding Description The audit identified material weakness and material noncompliance with federal program requirements related to payroll, fringe benefits and indirect costs. Specifically, FTCH did not comply with NIH Salary Cap requirements, which resulted in questioned costs that were quantitatively and qualitatively material. Cause of the Finding FTCH did not apply the NIH salary cap limitations correctly during the period under review. Corrective Action Planned • The Entity will take the following corrective actions to address the material noncompliance:  Performing a comprehensive review of all FTCH grants, both under consideration and currently active, to determine whether a salary cap limitation applies. Where applicable, management will confirm that the salary cap is being consistently and accurately applied in accordance with governing requirements. Any discrepancies identified have been or will be corrected in a timely manner.  Enhancing pre-award and pre-submission compliance controls through updates to grant review procedures and compliance checklists. These updates are designed to ensure that grants subject to salary cap limitations are clearly flagged and that salary calculations are reviewed and documented prior to submission and award acceptance.  Providing targeted training for staff involved in grant administration, budgeting, payroll processing, and financial reporting to ensure consistent understanding and application of salary cap requirements and related internal control procedures.  Conducting periodic internal monitoring reviews of salary charges to federal awards to assess ongoing compliance, validate the effectiveness of internal controls, and identify potential issues before they result in noncompliance. Results of these reviews will be documented, and corrective actions implemented as appropriate. Personnel Responsible: SVP Finance Anticipated Completion Date: May 31, 2026 Status of Corrective Action Corrective action has been initiated and will be completed within the stated timeframe. Management Certification Management certifies that the corrective actions described above are accurate, appropriate, and will be implemented as represented. ____________________ Matt Partridge SVP Finance April ___, 2026
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations We concur that the Corporation did not maintain the property in good repair and condition. S3800-130 Response Indicator Agree S3800-140 Completion Date 12/31/2025 S3800-150 Response The Corporation has addressed...
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations We concur that the Corporation did not maintain the property in good repair and condition. S3800-130 Response Indicator Agree S3800-140 Completion Date 12/31/2025 S3800-150 Response The Corporation has addressed the exigent health and safety issues. S3800-160 Contact Person First Name Jimmy S3800-180 Contact Person Last Name Wilson
Item: 2025-002 Assistance Listing Number: 17.280 Program: WIOA Dislocated Worker National Reserve Demonstration Grants Federal Agency: U.S. Department of Labor Pass-Through Agencies: n/a Contract/Pass-Through Grantor Identifying Number: 23A60YP000003 Award Year: September 30, 2023 to September 30, 2...
Item: 2025-002 Assistance Listing Number: 17.280 Program: WIOA Dislocated Worker National Reserve Demonstration Grants Federal Agency: U.S. Department of Labor Pass-Through Agencies: n/a Contract/Pass-Through Grantor Identifying Number: 23A60YP000003 Award Year: September 30, 2023 to September 30, 2026 Compliance Requirement: Subrecipeint Monitoring Criteria: A Pass-Through Entity (PTE) is required to monitor the activities of subrecipients as necessary to ensure that the subaward is used for authorized purposes, complies with the terms and conditions of the subaward, and achieves performance goals (2 CFR 200.332(d) through (f)). In addition to procedures identified as necessary based upon the evaluation of subrecipient risk or specifically required by the terms and conditions of the award, subaward monitoring must include the following: (a) reviewing financial and programmatic (performance and special reports) required by the PTE, (b) following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the federal award provided to the subrecipient from the PTE detected through audits, on-site reviews, and other means, and (c) issuing a management decision for audit findings pertaining to the federal award provided to the subrecipient from the PTE as required by 2 CFR 200.521. Condition: The Foundation did not complete the required subrecipient monitoring related to review of subrecipient Single Audits and financial statements. Specifically, we noted no evidence that the Foundation verified whether certain subrecipients met the Single Audit threshold under 2 CFR 200.501 or obtained the subrecipients’ Single Audit reporting packages from the Federal Audit Clearinghouse. Additionally, the Foundation did not obtain or document a review of the subrecipients’ audited financial statements (or other financial information) to inform the subrecipient risk assessment under 2 CFR 200.332(b). Name of Contact Person Steve Zylstra, President & CEO Phone Number: (602) 422-9447 Anticipated Completion Date: July 31, 2026 Views of Responsible Officials and Corrective Actions: For the current audit period, the Foundation has obtained the missing single audit reports and financial statements and is in the process of completing and documenting the required reviews, updating subrecipient risk ratings and performing any necessary follow-up or management decisions by April 30, 2026. Additionally, the Foundation will establish formal written procedures to comply with 2 CFR 200.332(b), (d), and (f), 2 CFR 200.501, and 2 CFR 200.521, including clear steps and timelines for verifying Single Audit applicability, obtaining and reviewing Single Audit reports, and issuing management decisions when applicable. Lastly, the Foundation will provide periodic training to finance and program staff on subrecipient monitoring requirements under the Uniform Guidance.
Item: 2025-001 Assistance Listing Number: 17.280 Program: WIOA Dislocated Worker National Reserve Demonstration Grants Federal Agency: U.S. Department of Labor Pass-Through Agencies: n/a Contract/Pass-Through Grantor Identifying Number: 23A60YP000003 Award Year: September 30, 2023 to September 30, 2...
Item: 2025-001 Assistance Listing Number: 17.280 Program: WIOA Dislocated Worker National Reserve Demonstration Grants Federal Agency: U.S. Department of Labor Pass-Through Agencies: n/a Contract/Pass-Through Grantor Identifying Number: 23A60YP000003 Award Year: September 30, 2023 to September 30, 2026 Compliance Requirement: Reporting - FFATA Criteria: The Federal Funding Accountability and Transparency Act (FFATA), as implemented by OMB at 2 CFR Part 170, requires prime recipients of federal awards to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Condition: The Foundation did not complete the required FFATA reporting in FSRS for applicable first-tier subawards. Name of Contact Person Steve Zylstra, President & CEO Phone Number: (602) 422-9447 Anticipated Completion Date: July 31, 2026 Views of Responsible Officials and Corrective Actions: The Foundation has corrected missed FFATA reporting by submitting outstanding subaward information to FSRS as of February 2026. Additionally, the Foundation will establish and document a FFATA reporting policy that defines the FFATA threshold and timing requirements. The Foundation will also assign clear responsibility for FFATA compliance and implement a monthly reconciliation of subaward obligations to FSRS submissions. Lastly, the Foundation will provide periodic training to grants, procurement, and finance staff on FFATA requirements and FSRS processes.
Management acknowledges noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management will monitor security deposit refunds in order to ensure refunds meet the Regulatory Agreement requirements.
Management acknowledges noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management will monitor security deposit refunds in order to ensure refunds meet the Regulatory Agreement requirements.
Finding 2025-002: Comments on the Finding and Each Recommendation: During the year ended December 31, 2025, one of the twenty-four resident files selected for testing under the OMB Compliance Supplement were unable to be located by the Agent. The Agent should review resident files completed by the F...
Finding 2025-002: Comments on the Finding and Each Recommendation: During the year ended December 31, 2025, one of the twenty-four resident files selected for testing under the OMB Compliance Supplement were unable to be located by the Agent. The Agent should review resident files completed by the Former Agent to ensure that all resident files include all properly executed and documented resident eligibility forms and ensure that these files are maintained at the Property for a minimum of three years. Action(s) taken or planned on the finding: The Agent concurs with the finding and the recommendation. The Agent will review resident files completed by the Former Agent to ensure that all resident files include all properly executed and documented resident eligibility forms and ensure that these files are maintained at the Property for a minimum of three years.
Finding 2025-001: Comments on the Finding and Each Recommendation: The Former Agent did not obtain a HUD approved Project Owner's/Management Agent's Certification (Form HUD-9839-B) and the Property paid unapproved management fees to the Former Agent. The Agent should obtain a HUD-approved Project Ow...
Finding 2025-001: Comments on the Finding and Each Recommendation: The Former Agent did not obtain a HUD approved Project Owner's/Management Agent's Certification (Form HUD-9839-B) and the Property paid unapproved management fees to the Former Agent. The Agent should obtain a HUD-approved Project Owner's/Management Agent's Certification. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. Management of the property transitioned to the Agent on June 1, 2025 and the Agent received a HUD-aproved Project Owner's/Management Agent's Certification for the Property.
FINDING 2025-003: Title I Eligibility Response: To ensure all records are correctly filed and maintained, the district is establishing new protocols for documenting Title eligibility.
FINDING 2025-003: Title I Eligibility Response: To ensure all records are correctly filed and maintained, the district is establishing new protocols for documenting Title eligibility.
This finding is due to the Township not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Township’s engineer has searched the state procurement office webpage to check if any vendor for a federal project...
This finding is due to the Township not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Township’s engineer has searched the state procurement office webpage to check if any vendor for a federal project is on the debarment list, which they are not. In the future, the Township will have controls in place to ensure that vendors are not debarred or suspended from federal funding awards. The person responsible for the corrective action is the Supervisor. The anticipated completion date of the corrective action plan is before the end of the 2026 fiscal year. The plan for adherence is the Board will review implement controls to ensure that vendors are not suspended, debarred, or otherwise excluded.
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