Corrective Action Plans

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ICCAP Management will strengthen internal controls over payroll by implementing a new daily time-tracking process within existing payroll procedures. Program Directors will enforce a mandatory 15-minute end-of-day shutdown period for staff to coplete time and activity entries. Directors will also be...
ICCAP Management will strengthen internal controls over payroll by implementing a new daily time-tracking process within existing payroll procedures. Program Directors will enforce a mandatory 15-minute end-of-day shutdown period for staff to coplete time and activity entries. Directors will also be required to verify that all activities recorded on employee timesheets can be supported by case notes, reports, or direct visual confirmation. The fiscal department will review and address any shortages in federal funding related to payroll and will identify the approrpiate support program for reallocation prior to receiving bi-weekly payroll documentation.
We will put procedures in place within our Accounting policy to ensure reports are reviewed/approved and are submitted timely.
We will put procedures in place within our Accounting policy to ensure reports are reviewed/approved and are submitted timely.
Federal Agency Name: U.S. Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: Inaccurate reporting procedures were noted in 2 quarter’s performance reports. Corrective Action Plan: Each quarter, County grant staff ...
Federal Agency Name: U.S. Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: Inaccurate reporting procedures were noted in 2 quarter’s performance reports. Corrective Action Plan: Each quarter, County grant staff report ARPA project expenditures that incurred during the reporting period in the online U.S. Department of Treasury’s COVID-19 Relief Hub (the Treasury portal). For all open projects, staff must manually enter total cumulative expenditures, current period obligations, and current period expenditures. In some cases, expenditures cannot be entered within the “Project Overview” section and must be entered separately in the “Expenditure” section of the Treasury portal, creating an additional step of manual data entry to record quarterly expenditures. The County has identified several system limitations within the Treasury portal that increase the risk of reporting errors. The Treasury portal does not calculate cumulative expenditures automatically; cumulative expenditure totals must be manually re-entered for each reporting period. Current period expenditures do not automatically roll into cumulative totals. The Treasury portal also lacks automated reconciliation or validation checks, meaning that errors in current period expenditure entries are not flagged and will not be reflected in cumulative expenditure totals. Additionally, the Treasury portal does not allow copying and pasting of data, requiring all amounts to be entered manually, which further increases the risk of data entry errors. To address these limitations and strengthen controls, County staff have implemented the following corrective actions: 1. Quarterly Project-Level Reconciliation Control A formal quarterly reconciliation process has been implemented at the individual project level. For each reporting period: • Each project expenditure that is recorded for the reporting period is reconciled to the internal project tracking spreadsheet, rather than only reconciling the total cumulative expenditures that appear on the front Project Overview page of the COVID-19 Relief Hub. o The internal tracking spreadsheet is updated quarterly using data from the General Ledger and individual ARPA project financial reports. • After entering expenditures into the Treasury portal is completed, staff re-open each project entry to verify accuracy and confirm that expenditures were entered correctly and no errors occurred. • Staff check for expenditure accuracy in both the “Project Status” and “Expenditure Status” tab in the Treasury portal, to ensure expenditures match and were recorded correctly. 2. Secondary Review Control All Treasury reports have a secondary review prior to submission. • The Grants Specialist prepares and enters the report. • The Grants and Procurement Director independently reviews reported amounts against the internal tracking spreadsheet. • Any discrepancies are resolved prior to report submission. This dual-review process provides segregation of duties and reduces the risk of undetected reporting errors. These procedures have been implemented and will be consistently applied for all future reporting periods to ensure accurate, complete, and reliable reporting. Responsible Individual(s): Ann McCauley, Grants and Procurement Director Elisa Fiaschetti, ARPA Program and Grants Specialist Anticipated Completion Date: January 2026
Finding #2025-001 – Lack of Segregation of Duties (Prior Year Finding #2024-001) Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Criteria: Checks and balances should be in place to allow management or employees, in the normal course of pe...
Finding #2025-001 – Lack of Segregation of Duties (Prior Year Finding #2024-001) Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Criteria: Checks and balances should be in place to allow management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct any misstatements on a timely basis. Cause: A small number of individuals within the District’s administration perform substantially all accounting functions and have control over both records and assets. Effect: Because of the lack of segregation of duties, errors or irregularities could occur and not be detected on a timely basis. Recommendation: Procedures should be implemented segregating duties among different employees. Management should continue to maintain a working knowledge of matters relating to the District’s operations. Response: We agree and will continue to provide supervision and monitor accounting information and operations, obtain explanations for variances from unexpected results and work to increase segregation of duties. The Assistant to the Business Manager will continue to clear checks in Skyward as part of the bank reconciliation process. The District Administrator will review and initial all journal entries. The Assistant to the Business Manager will review payroll on a monthly basis, and the District Administrator will review payroll on a quarterly basis.
Finding 2025-103: Cash Management - Criteria: The recipient must: establish, document, and maintain effective internal control over the federal award that provides reasonable assurance that the recipient is managing the federal award in compliance with federal statutes, regulations, and terms and co...
Finding 2025-103: Cash Management - Criteria: The recipient must: establish, document, and maintain effective internal control over the federal award that provides reasonable assurance that the recipient is managing the federal award in compliance with federal statutes, regulations, and terms and conditions of the federal award. Condition: Non-Federal entities funded under the reimbursement method must maintain documentation to support that reimbursement was requested prior to the date of the reimbursement request. There were no documented review controls indicating a secondary review of expenditures prior to draw down. Context: For four cash drawdowns, there was no documentation over review of the drawdown support prior to requesting the funds. Cause: There was a lack of review of the drawdowns. Effect: Drawdown requests were not reviewed prior to submission Questioned Costs: None. Repeat Finding: No. Recommendation: All drawdown support should be reviewed prior to requesting the funds. Contact: Vincent Rivers, Executive Director. Corrective Actions Taken or Planned: We have implemented a policy for a program manager to review grant drawdown support prior to requesting funds.
Allowable Cost Approval - Criteria: The recipient must: establish, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the recipient is managing the federal award in compliance with federal statutes, regulations, and terms and conditions o...
Allowable Cost Approval - Criteria: The recipient must: establish, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the recipient is managing the federal award in compliance with federal statutes, regulations, and terms and conditions of the federal award. Condition: Payroll is an allowable cost per the grant agreement once approved by DESE in the program budget. Employee changes throughout the year require reapproval of the budget. The Center did not maintain documentation to support reapprovals and budget changes during the year, nor was there any documented review of the budget change submitted. Context: For twenty-five payroll selections, there was no documentation maintained to support a direct correlation to the approved payroll budget. Cause: Due to the size of the entity, the Executive Director is the only one that processes and reviews grant expenditures. Effect: No documentation was maintained to support review of the payroll expenditures when changes were made to the grant. Questioned Costs: None. Repeat Finding: No. Recommendation: Implement review procedures over allowable cost to ensure all employees charged to the grant have received DESE approval. Contact: Vincent Rivers, Executive Director. Corrective Actions Taken or Planned: We have implemented a policy for a program manager to review all allowable cost.
Eligibility Documentation - Criteria: Eligible individuals are individuals who are at least 16 years of age, who are not enrolled or required to be enrolled in secondary school under state law, and who are basic skills deficient, do not have a secondary school diploma or its recognized equivalent an...
Eligibility Documentation - Criteria: Eligible individuals are individuals who are at least 16 years of age, who are not enrolled or required to be enrolled in secondary school under state law, and who are basic skills deficient, do not have a secondary school diploma or its recognized equivalent and have not achieved an equivalent level of education, or are English language learners (29 USC 3272(4)). Condition: Students are required to fill out an application prior to being admitted to the program. The Center reviews the application and inputs the data into the Department of Elementary and Secondary Education (DESE) system, however does not maintain the applications to support that the students met the eligibility requirements. Context: For twenty-five student selections, there was no documentation maintained to support student age. Cause: Documentation was shredded due to personal information. Effect: Documentation was not maintained to support compliance with the standards. Questioned Costs: None. Repeat Finding: No. Recommendation: Documentation should be maintained to support all eligible students enrolled in the program. Contact: Vincent Rivers, Executive Director. Corrective Actions Taken or Planned: We have implemented a policy to scan and maintain all student applications on the network.
The University of Massachusetts acknowledges the enrollment status of certain students was not accurately or timely transmitted to the National Student Loan Data System (NSLDS). The University will implement additional controls and procedures to ensure data is transmitted to NSLDS correctly and time...
The University of Massachusetts acknowledges the enrollment status of certain students was not accurately or timely transmitted to the National Student Loan Data System (NSLDS). The University will implement additional controls and procedures to ensure data is transmitted to NSLDS correctly and timely, including increased reviews of data submitted to NSDLS, and a reconciliation of student status with NSLDS. The corrective action plan will be implemented by May 31, 2026. For further details regarding the corrective action plan, contact the Assistant Vice President and University Controller, Patrick Hitchcock, at phitchcock@umassp.edu
Identifying Number: 2025-003: U.S. Department of Education: Federal Direct Student Loans – 84.268 Finding: During testing over enrollment reporting, one instance was identified where a student’s program begin date was incorrectly reported to NDSLDS. Corrective Action Taken or Planned: There were sev...
Identifying Number: 2025-003: U.S. Department of Education: Federal Direct Student Loans – 84.268 Finding: During testing over enrollment reporting, one instance was identified where a student’s program begin date was incorrectly reported to NDSLDS. Corrective Action Taken or Planned: There were several instances of dates submitted through the National Student Clearinghouse to NSLDS where dates were not aligning to submissions. In all but one case, those dates were confirmed to be matching the NSC submission and were not found to be erroneous. The one date is suspected to be due to a program change and those students with changes will be monitored by the Registrar and the Financial Aid Office. Contact person: Micah Hansen, Director of Financial Aid Status of finding – The above corrective actions will be implemented beginning January 1, 2026.
Identifying Number: 2025-002: U.S. Department of Education: Federal Direct Student Loans – 84.268; Federal Pell Grant Program – 84.007 Finding: During testing over credit balances, it was noted that one student did not receive the refund on a timely basis. Corrective Action Taken or Planned: All sch...
Identifying Number: 2025-002: U.S. Department of Education: Federal Direct Student Loans – 84.268; Federal Pell Grant Program – 84.007 Finding: During testing over credit balances, it was noted that one student did not receive the refund on a timely basis. Corrective Action Taken or Planned: All scheduled disbursements will be reviewed to ensure they are provided on a timely basis and are applied correctly to prior award years. Business Office procedures and processing will be reviewed to ensure that credit balances are processed within the regulatory timeframe. New staff have been trained to monitor dates for compliance and have implemented checks with the Financial Aid Office. Contact person: Micah Hansen, Director of Financial Aid and Christine Goldsmith, Vice President - Finance Status of finding – The above corrective actions will be implemented beginning January 1, 2026.
Current Finding (2025-002) Missing Claims Auditor Approval As a part of the Special Education Cluster, the claims auditor approval was missing from 1 of 4 selections. Improper funds were distributed by the District that did not follow New York State requirements. Corrective Action Plan (a) Implement...
Current Finding (2025-002) Missing Claims Auditor Approval As a part of the Special Education Cluster, the claims auditor approval was missing from 1 of 4 selections. Improper funds were distributed by the District that did not follow New York State requirements. Corrective Action Plan (a) Implementation plan of actions: Management will ensure that all call disbursements have been reviewed by the claims auditor prior to releasing checks. (b) Implementation date: This will be implemented on March 31, 2026. (c) Person responsible for implementation: Jamal Scott, Assistant Superintendent for Business and Operations. (d) Completion date: This will be completed on or prior to June 30, 2026.
Contact Person – Rebecca Krein, Business Manager Corrective Action Plan – Little Eagle Grant School acknowledges the finding regarding being unable to provide the schools policy detailing test security measures. The school has drafted a policy regarding the entire Title I program that will be approv...
Contact Person – Rebecca Krein, Business Manager Corrective Action Plan – Little Eagle Grant School acknowledges the finding regarding being unable to provide the schools policy detailing test security measures. The school has drafted a policy regarding the entire Title I program that will be approved on March 30, 2026. Completion Date – March 30, 2026
Contact Person – Rebecca Krein, Business Manager Little Eagle Grant School acknowledges the finding regarding insufficient payroll documentation. To address this, the School will implement a standardized certification form to be submitted with each employee timesheet. This form will require employee...
Contact Person – Rebecca Krein, Business Manager Little Eagle Grant School acknowledges the finding regarding insufficient payroll documentation. To address this, the School will implement a standardized certification form to be submitted with each employee timesheet. This form will require employees to certify that their time and effort were performed in accordance with the approved budget and assigned funding source(s). This process will strengthen documentation and ensure compliance with federal requirements moving forward. Completion Date – April 1, 2026
The Organization will adopt formal procedures to assess FFATA applicability for every subaward, require FFATA reporting in FSRS.gov by the end of the month following the subaward obligation, and train program and grants staff on FFATA requirements and documentation.
The Organization will adopt formal procedures to assess FFATA applicability for every subaward, require FFATA reporting in FSRS.gov by the end of the month following the subaward obligation, and train program and grants staff on FFATA requirements and documentation.
The organization will revise and reinforce its procurement policies to ensure compliance with 2 CFR 200.318–200.320. Staff involved in procurement will receive training in federal procurement standards, including competitive bidding and documentation requirements. Internal controls will be strengthe...
The organization will revise and reinforce its procurement policies to ensure compliance with 2 CFR 200.318–200.320. Staff involved in procurement will receive training in federal procurement standards, including competitive bidding and documentation requirements. Internal controls will be strengthened to ensure consistent application of procedures and oversight.
The audit engagement letter will include the 90-day requirement for completion of the audit for fiscal year ending June 30, 2026.
The audit engagement letter will include the 90-day requirement for completion of the audit for fiscal year ending June 30, 2026.
Finding Number: 2025-005 Condition: The College did not include their Community Facilities Loans on the Schedule of Federal Expenditures in prior years. Planned Corrective Action: The College will ensure that updates to compliance requirements are identified and complied with through review of Compl...
Finding Number: 2025-005 Condition: The College did not include their Community Facilities Loans on the Schedule of Federal Expenditures in prior years. Planned Corrective Action: The College will ensure that updates to compliance requirements are identified and complied with through review of Compliance supplements and other resources. The College will continue to reconcile grant funds received to the SEFA to ensure that all appropriate programs are included. Contact person responsible for corrective action: Kayla Flanders Anticipated Completion Date: 6/30/2026
Finding Number: 2025-009 Condition: The College did not have established written cash management procedures. Planned Corrective Action: The College agrees with the finding. Although the College has processes in place to ensure appropriateness of draws and review of expenditures both individually and...
Finding Number: 2025-009 Condition: The College did not have established written cash management procedures. Planned Corrective Action: The College agrees with the finding. Although the College has processes in place to ensure appropriateness of draws and review of expenditures both individually and in aggregate, the process and procedures are not documented. The College will document cash management procedures and related internal controls. Contact person responsible for corrective action: Kayla Flanders Anticipated Completion Date: 6/30/2026
Finding Number: 2025-008 Condition: The College did not accurately report certain changes to NSLDS. Planned Corrective Action: The College agrees with the finding. The College acknowledges the error in reporting. The College will evaluate its internal control processes around data transmission throu...
Finding Number: 2025-008 Condition: The College did not accurately report certain changes to NSLDS. Planned Corrective Action: The College agrees with the finding. The College acknowledges the error in reporting. The College will evaluate its internal control processes around data transmission through a third party to ensure that information is accurately reported to avoid future errors and make enhancements and improvements as necessary. Contact person responsible for corrective action: Kayla Flanders Anticipated Completion Date: 6/30/2026
Finding Number: 2025-007 Condition: The College did not have appropriate internal controls in place related to the version updates, patches, and modifications in the student and general ledger systems. Planned Corrective Action: The College agrees with the finding. The CFO and Controller will work w...
Finding Number: 2025-007 Condition: The College did not have appropriate internal controls in place related to the version updates, patches, and modifications in the student and general ledger systems. Planned Corrective Action: The College agrees with the finding. The CFO and Controller will work with the CIO to ensure that appropriate internal controls, including segregation of duties, around system upgrades, patches and modifications are completed. The internal control processes will cover the following key areas: • Planning and Authorization of the upgrade, patch or change • Implementation and Testing of the upgrade, patch or change, including user acceptance testing • Change Management and Documentation of the change, including logs or appropriate audit trails • Post Implementation Monitoring and Review Contact person responsible for corrective action: Kayla Flanders Anticipated Completion Date: 6/30/2026
Finding Number: 2025-006 Condition: The College did not notify students receiving loan or TEACH disbursements within 30 days of crediting the students' account. Planned Corrective Action: The College agrees with the finding. The College will review the internal processes and procedures around studen...
Finding Number: 2025-006 Condition: The College did not notify students receiving loan or TEACH disbursements within 30 days of crediting the students' account. Planned Corrective Action: The College agrees with the finding. The College will review the internal processes and procedures around student notification to ensure that all required notifications are completed within the designated timeframe. The CFO and Controller will work with the Financial Aid office to ensure the process is documented and complied with. Contact person responsible for corrective action: Kayla Flanders Anticipated Completion Date: 6/30/2026
In the future, the Treasurer will ensure proper procurement methods are followed to be certain we are utilizing the most cost effective and qualified vendor(s). This finding was due to the Food Service Director not seeking at least two quotations, per our procurement policy for federal funds.
In the future, the Treasurer will ensure proper procurement methods are followed to be certain we are utilizing the most cost effective and qualified vendor(s). This finding was due to the Food Service Director not seeking at least two quotations, per our procurement policy for federal funds.
We concur with the finding. The Municipality has reclassified all expenditures to the appropriate program fund and project codes corresponding to each individual PW. In addition, the Finance Department has assigned program and accounting staff to ensure the proper recording and classification of exp...
We concur with the finding. The Municipality has reclassified all expenditures to the appropriate program fund and project codes corresponding to each individual PW. In addition, the Finance Department has assigned program and accounting staff to ensure the proper recording and classification of expenditures, thereby maintaining compliance with FEMA and other funding requirements. Implementation date: February 23, 2026 Responsable Person: Mrs. Omayra Báez Caraballo Finance Department Director
We concur with the finding. The Municipality has implemented the following corrective measures: The Municipality provides training to personnel responsible for grant reporting, covering the preparation and timely submission of all CDBG financial reports, including proper documentation and reconcilia...
We concur with the finding. The Municipality has implemented the following corrective measures: The Municipality provides training to personnel responsible for grant reporting, covering the preparation and timely submission of all CDBG financial reports, including proper documentation and reconciliation of program expenditures. The Municipality has assigned a staff member to monitor all grant reporting deadlines and coordinate with the pass-through entity to ensure timely report submissions. Implementation date: July 1, 2026 Responsible Person: Mrs. Omayra Báez Caraballo Finance Department Director
Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated December 4, 2025 titled Noncompliance with Managed Care Provider Enrollment and Screening Requirement. LDH appreciates the opportunity to provide th...
Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated December 4, 2025 titled Noncompliance with Managed Care Provider Enrollment and Screening Requirement. LDH appreciates the opportunity to provide this response to your office's findings. Finding: Noncompliance with Managed Care Provider Enrollment and Screening Requirement. Recommendation: LDH should ensure all providers are screened and enrolled as required by federal regulations. LDH Response: LDH concurs with the LLA's finding and has determined the factors that resulted in certain providers not being enrolled as required. Corrective Action: Both system enhancements and procedural modifications are necessary to ensure that all providers are appropriately screened and enrolled. LDH has identified the following contributing factors and has initiated the requisite corrective actions with Gainwell Technologies: 1. Certain Fee-for-Service (FFS) providers undergoing a change of ownership (CHOW) did not have their updated National Provider Identifier (NPI) accurately reflected in the provider enrollment portal, causing them to be classified as unenrolled. Corrective Action Plan: The strengthening of the current process will ensure that all new CHOW updates received are recorded as part of standard daily operations within both the FFS and Provider Enrollment Portal environments. In parallel, the development of a defined solution path for automating the historical CHOW reconciliation remains underway, with full end-to-end automation identified as a longer-term 2026 priority milestone. This project is presently in tech assessment status. 2. Some providers were not invited to initiate the enrollment process because they did not meet the established eligibility criteria. Corrective Action Plan: A comprehensive review of the established inclusion criteria will be conducted to determine which criteria should be amended, retained, or removed. Corresponding procedural and system modifications will be implemented to ensure that all eligible providers are appropriately invited to enroll. Corrective action is expected to be completed by March 31, 2026. 3. Certain Durable Medical Equipment (DME) provider records were configured in a manner that inadvertently excluded them from the active provider population displayed in the enrollment portal. Corrective Action Plan: A comprehensive review of DME provider records associated with the exclusionary provider cancel reason code 38 will be conducted to identify records eligible for reactivation. Records verified as holding valid and current accreditation will be reprocessed for inclusion in the Provider Enrollment Portal, whereas records with unresolved compliance issues will remain inactive until the required documentation is received. Corrective action is expected to be completed by March 31, 2026. You may contact Seth Gold, Medicaid Executive Director at (225) 219-7810 or via e­ mail at Seth.Gold@la.gov or Brandon Bueche, Medicaid Deputy Director at (225) 384-0460 or via e-mail at Brandon.Bueche@la.gov with any questions about this matter.
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