Corrective Action Plans

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Management Response - The District Superintendent and Business Manager review and approve the financial statements. Upon completion of the full audit, the school board reviews, comments on, and approves the audited financial statements.
Management Response - The District Superintendent and Business Manager review and approve the financial statements. Upon completion of the full audit, the school board reviews, comments on, and approves the audited financial statements.
Management Response – Because of the size of the office and the district, we are precluded from maintaining a proper staff size to ensure a proper segregation of duties. We are aware of this condition, and we realize that the concentration of duties and responsibilities in a limited number of indivi...
Management Response – Because of the size of the office and the district, we are precluded from maintaining a proper staff size to ensure a proper segregation of duties. We are aware of this condition, and we realize that the concentration of duties and responsibilities in a limited number of individuals in not desirable for an effective system of internal control. To mitigate the issue of lack of segregation of duties, we have cross trained virtually each of the business office employees. While we do have a dedicated payroll person, another individual will perform cross checks & verifications independently. The same goes for issuing checks, accounts receivable, accounts payable, and activity funds. These functions are overseen by the business manager.
Management agrees with the finding and the funds were deposited to the reserve on July 16, 2024.
Management agrees with the finding and the funds were deposited to the reserve on July 16, 2024.
Management Response - The District Superintendent and Business Manager review and approve the financial statements. Upon completion of the full audit, the school board reviews, comments on, and approves the audited financial statements.
Management Response - The District Superintendent and Business Manager review and approve the financial statements. Upon completion of the full audit, the school board reviews, comments on, and approves the audited financial statements.
Management Response – Because of the size of the office and the district, we are precluded from maintaining a proper staff size to ensure a proper segregation of duties. We are aware of this condition, and we realize that the concentration of duties and responsibilities in a limited number of indivi...
Management Response – Because of the size of the office and the district, we are precluded from maintaining a proper staff size to ensure a proper segregation of duties. We are aware of this condition, and we realize that the concentration of duties and responsibilities in a limited number of individuals in not desirable for an effective system of internal control. To mitigate the issue of lack of segregation of duties, we have cross trained virtually each of the business office employees. While we do have a dedicated payroll person, another individual will perform cross checks & verifications independently. The same goes for issuing checks, accounts receivable, accounts payable, and activity funds. These functions are overseen by the business manager.
The management agent will repay the funds on behalf of the related party housing project until that property has funds available, pending HUD approval.
The management agent will repay the funds on behalf of the related party housing project until that property has funds available, pending HUD approval.
Management agrees and is working to submit a RAD for PRAC application that would include this property and two other properties.
Management agrees and is working to submit a RAD for PRAC application that would include this property and two other properties.
Management agrees and is working to submit a RAD for PRAC application that would include this property and two other properties.
Management agrees and is working to submit a RAD for PRAC application that would include this property and two other properties.
Finding # 2025-003 Type: Material weakness reporting Type: Noncompliance over reporting Assisting Listing Number: 43.001 Federal Agency: National Aeronautics and Space Administration Name of Federal Program: Science Finding: The FFR were not reviewed prior to submission by a secondary individual and...
Finding # 2025-003 Type: Material weakness reporting Type: Noncompliance over reporting Assisting Listing Number: 43.001 Federal Agency: National Aeronautics and Space Administration Name of Federal Program: Science Finding: The FFR were not reviewed prior to submission by a secondary individual and were not submitted timely. Federal Financial Reports (FFR) are due within 30 days following the end of each quarter. There should be controls in place to ensure reports are prepared, reviewed and submitted timely. Recommendation: Management should establish a consistent procedure to review and approve reports before submission by a member of management different from the preparer. Corrective Action: The review and late filing noted was the result of a temporary administrative disruption caused by a transition in the Chief Financial Officer role, which included a brief loss of account access necessary to prepare and submit the report. This access issue has been fully resolved and appropriate controls and staffing transition plans are in place. We have implemented a tracking system to ensure all required reports are compiled, reviewed, and submitted prior to the applicable deadline. Anticipated Completion Date December 20, 2025
Finding # 2025-002 Type: Material weakness over procurement Type: Noncompliance over procurement Assisting Listing Number: 43.001 Federal Agency: National Aeronautics and Space Administration Name of Federal Program: Science Finding: The Organization does not have controls or a policy in place to en...
Finding # 2025-002 Type: Material weakness over procurement Type: Noncompliance over procurement Assisting Listing Number: 43.001 Federal Agency: National Aeronautics and Space Administration Name of Federal Program: Science Finding: The Organization does not have controls or a policy in place to ensure compliance with this requirement. Non-federal entities are prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. “Covered transactions” include contracts for goods and services awarded under a non-procurement transaction (e.g., grant or cooperative agreement) that are expected to equal or exceed $25,000 or meet certain other criteria as specified in 2 CFR section 180.220. All non-procurement transactions entered into by a pass-through entity (i.e., subawards to subrecipients), irrespective of award amount, are considered covered transactions, unless they are exempt as provided in 2 CFR section 180.215. Recommendation: Management should establish a consistent procedure to verify that vendors are not suspended or debarred and implement controls that are documented to support this process. A procurement policy should also be implemented consistent with the aforementioned guidance. Corrective Action: While we did not previously have a standalone, written policy specifically addressing suspension and debarment, key elements of procurement oversight, including suspension and debarment review, were incorporated into existing policies and operational practices. The new procurement policy consolidates and formally documents these requirements to ensure consistency, clarity, and ongoing compliance. In addition, we took the opportunity to review and revise our detailed procedures for setting up new vendors and retaining documentation for all required vendor confirmation. Anticipated Completion Date: December 20, 2025
Finding # 2025-001 Type: Material weakness over allowable costs Type: Immaterial noncompliance over allowable costs Assisting Listing Number: 43.001 Federal Agency: National Aeronautics and Space Administration Name of Federal Program: Science Finding: One individual computes the indirect charges an...
Finding # 2025-001 Type: Material weakness over allowable costs Type: Immaterial noncompliance over allowable costs Assisting Listing Number: 43.001 Federal Agency: National Aeronautics and Space Administration Name of Federal Program: Science Finding: One individual computes the indirect charges and prepares the drawdown requests without a secondary review by a senior member of management. Two out of forty expenses tested were completed by one individual with no review. Three out of four cash draws tested were submitted with no secondary review. Immaterial errors were noted in amounts charged for indirect costs. Recommendation: Management should establish a consistent procedure to ensure indirect rate calculations and monthly billings are reviewed prior to submission. Corrective Action: As a result of administrative disruption caused by a transition in the Chief Financial Officer role, we were required to catch up as quickly as possible. During this catch-up period, normal review processes were not fully in place due to the noted staff transitions. This was a one-time situation and has since been remedied through the implementation of formalized policies and procedures governing the preparation, review, and timely submission of federal reports. We have transitioned to an accounting software that limits the ability for indirect rate calculations to be completed by one individual. Monthly draw requests will be completed by the Finance Director during month-end close and submitted to the Chief Financial Officer for review prior to submission. Anticipated Completion Date: December 20, 2025
Management should develop a system that ensures that future Single Audit packages are submitted on time.
Management should develop a system that ensures that future Single Audit packages are submitted on time.
Condition: The required capital outlay log amounts had several capital outlay line items that did not match the cost recorded in the general ledger. Recommendation: It is recommended, at year end, that the District should compare the capital outlay log to the general ledger to ensure the costs match...
Condition: The required capital outlay log amounts had several capital outlay line items that did not match the cost recorded in the general ledger. Recommendation: It is recommended, at year end, that the District should compare the capital outlay log to the general ledger to ensure the costs match. Management Response: The Director of Finance or designee will review all capital outlay logs and reconcile them to the general ledger before year-end. In addition, training will be provided to grant coordinators to ensure they are completing the log correctly. Anticipated Date of Completion: June 30, 2026
Finding 2025-001: Comments on the Finding and Each Recommendation All the required monthly reserve for replacements deposits were not made during the year ended September 30, 2025. Management should transfer $5,692 into the reserve for replacements account from the operating cash account as soon as ...
Finding 2025-001: Comments on the Finding and Each Recommendation All the required monthly reserve for replacements deposits were not made during the year ended September 30, 2025. Management should transfer $5,692 into the reserve for replacements account from the operating cash account as soon as possible. Action(s) taken or planned on the finding Management concurs with the finding and agrees with the recommendation and on December 17, 2025 transferred $5,692 from the operating cash account to the reserve for replacements account.
In relation to Family Health Center of San Diego’s annual financial statement audit and the single audit for the year ended June 30, 2025, the Health Center hereby submits a corrective action plan, as required by Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements,...
In relation to Family Health Center of San Diego’s annual financial statement audit and the single audit for the year ended June 30, 2025, the Health Center hereby submits a corrective action plan, as required by Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Section 511 Audit findings follow-up. 2025-001 – Special Tests and Provisions (Sliding Fee Discounts) Information on the Federal Program: Assistance Listing Number(s): 93.224, 93.527 Federal Program Name: Health Center Program Cluster Federal Agency: U.S. Department of Health and Human Services Pass-Through Entity: Direct Program Federal Award Number and Award Year: 5 H80CS00224‐23‐00 – 2023-2024 5 H80CS00224‐24‐00 – 2024-2025 Criteria: In accordance with the Health Resources & Services Administration Health Center Program Compliance Manual, Chapter 9: Sliding Fee Discount Program, health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted based on the patients’ ability to pay. In accordance with 42 CFR 56.303, health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by U.S. Department of Health and Human Services (HHS). The schedule of discounts must provide for a full discount to individuals and families with annual incomes at or below those set forth in the most recent poverty income guidelines (except that nominal fee for service may be collected from such individuals and families) and for no discount to individuals and families with annual incomes greater than twice those set forth in such guidelines. Condition and Context: The Health Center determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discount, we noted the following: • Four (4) out of 60 encounters selected were given a sliding fee discount in an amount that did not match the recalculated sliding fee discount based on annual gross income and household size per the sliding fee policy. There was a total of 65,495 encounters and the sample procedures were not statistical. Questioned Costs: None. 2025-001 – Special Tests and Provisions (Sliding Fee Discounts) (Continued) Cause: During a system transition period, monitoring controls were ineffective, resulting in documentation variances and system-related issues. Contributing factors included documentation timing differences, manual data entry variances, and previously identified electronic health record system mapping defects affecting fee calculation and form generation. Effect: Patients were given an improper sliding fee discount based on their income and family size. Indication of Repeat Finding: No. Recommendation: We recommend that the Health Center strengthen documentation practices and monitoring procedures related to the Sliding Fee Discount Program, particularly during periods of system or workflow transition. Views of Responsible Officials and Planned Corrective Actions: Management concurs in part with the finding. While isolated documentation variances were identified in a non-statistical sample, management determined the condition was limited in scope, not systemic, and resulted in no questioned costs. The variances were associated with a temporary system transition period and documentation timing issues, not a deficiency in internal controls. Corrective actions were implemented, system issues were resolved, and results were validated through a full-population review. Management will continue ongoing monitoring to ensure sustained compliance. Contact person responsible for corrective action: Ricardo Roman, Chief Financial Officer Anticipated completion date: June 30, 2026
Action Taken: CCYSB will ensure that all documentation regarding a federal program is properly collected, stored, and verified on a quarterly basis. To verify data reporting accuracy, the Program Director will provide the supporting data to the Grants Manager for review prior to completion of the re...
Action Taken: CCYSB will ensure that all documentation regarding a federal program is properly collected, stored, and verified on a quarterly basis. To verify data reporting accuracy, the Program Director will provide the supporting data to the Grants Manager for review prior to completion of the report. CCYSB will ensure that once verified, the information submitted in any report will not contain any discrepancies from that which was verified and that we have all the necessary supporting documentation to justify the reporting.
We will review procedures and plan to make the necessary changes to improve internal control.
We will review procedures and plan to make the necessary changes to improve internal control.
The District relies on the auditor to propose adjustments necessary to prepare the schedule of expenditures of federal awards including the related note disclosures. The District reviews the schedule of expenditures of federal awards and approves all adjustments.
The District relies on the auditor to propose adjustments necessary to prepare the schedule of expenditures of federal awards including the related note disclosures. The District reviews the schedule of expenditures of federal awards and approves all adjustments.
2025-002 – Education Stabilization Fund – Activities Allowed or Unallowed and Allowable Costs and Cost Principles Condition 26 employees worked Summer School hours that were funded by Education Stabilization Fund monies, and while it was noted by staff that timesheets were prepared for these hours, ...
2025-002 – Education Stabilization Fund – Activities Allowed or Unallowed and Allowable Costs and Cost Principles Condition 26 employees worked Summer School hours that were funded by Education Stabilization Fund monies, and while it was noted by staff that timesheets were prepared for these hours, they could not be located during audit procedures. Recommendation The District should carefully review all charges to the federal award in order to ensure that sufficient supporting documentation has been obtained, that correct payments are being made, and that no unreasonable or unnecessary charges exist. Comments on the Finding The District agrees with the finding and has implemented procedures to prevent this, in the future. Actions Taken All timesheets are now required to be submitted to Human Resources during payroll processing, and they will be kept on file in an easily identifiable manner. This will help to ensure that payroll costs are correctly calculated and properly documented.
Condition During testing, auditor determined that 24 students had an incorrect eligibility status utilized for a portion of the school year. Recommendation We recommend that the District look for training opportunities for food service staff members to ensure that they have a good understanding of t...
Condition During testing, auditor determined that 24 students had an incorrect eligibility status utilized for a portion of the school year. Recommendation We recommend that the District look for training opportunities for food service staff members to ensure that they have a good understanding of the program’s compliance requirements. Additionally, all students receiving free or reduced price meal benefits should be reviewed to ensure that they have a valid application or direct certification on file. Comments on the Finding The District agrees with the finding and has implemented procedures to prevent this, in the future. Actions Taken As of the date of this notice, training opportunities will be sought out to further food service staff members’ educations regarding the program compliance requirements. Eligibility for all students will be reset each year to ensure that only those who are direct certified or that have submitted an application and are eligible for free or reduced meals will receive those benefits.
2025-003 – Child Nutrition Cluster – Activities Allowed or Unallowed and Allowable Costs and Cost Principles and Reporting Condition During testing of the sponsor claim reimbursement reports, it was found that the District submitted inaccurate meal counts on two monthly reports. Recommendation We re...
2025-003 – Child Nutrition Cluster – Activities Allowed or Unallowed and Allowable Costs and Cost Principles and Reporting Condition During testing of the sponsor claim reimbursement reports, it was found that the District submitted inaccurate meal counts on two monthly reports. Recommendation We recommend that the District review its controls related to monthly reimbursement requests for the Child Nutrition Cluster in order to ensure that accurate meal counts are submitted. Comments on the Finding The District agrees with the finding and has implemented procedures to prevent this, in the future. Actions Taken As of the date of this notice, reimbursement claims will be prepared using the Power School software’s meal counts, and the claim will be reviewed by an individual other than the preparer before being submitted.
Finding: During the audit, it was identified that severance pay for a former employee was charged to the Title I, Part A program. This expenditure is unallowable under 2 CFR §200.431(i), which permits severance payments only when reasonable, necessary, and consistent with written policy and prior ap...
Finding: During the audit, it was identified that severance pay for a former employee was charged to the Title I, Part A program. This expenditure is unallowable under 2 CFR §200.431(i), which permits severance payments only when reasonable, necessary, and consistent with written policy and prior approval requirements. Root Cause: The unallowable cost occurred due to a breakdown in internal controls among Payroll, HR, Finance, and Federal Programs. The Payroll Department processed the severance payment without verifying the funding source’s allowability, and there was no secondary review by Finance, HR, or Federal Programs to identify and reclassify the cost prior to posting. This lack of coordinated oversight led to the unallowable charge to Title I, Part A. Corrective Action Steps 1. Reimbursement of Unallowable Costs o The organization will reimburse the Title I, Part A program from local funds for the total amount of severance pay charged in error. o Documentation of the reimbursement (journal entry and general ledger report) will be retained in the audit file. 2. Policy and Procedure Revision o The organization will revise its federal programs expenditure review, payroll, finance, and HR procedures to ensure all personnel-related transactions - including severance, stipends, and separation payments - are reviewed for federal allowability before processing. o Payroll must verify the allowability of the funding source with the Federal Programs Office prior to processing any non-routine payments. o HR will confirm appropriate coding and funding source alignment during separation processing. o A pre-approval checklist will be implemented for all employee separation and severance actions. 3. Staff Training o Payroll, HR, Finance, and Federal Programs staff will receive targeted training on EDGAR Subpart E (Cost Principles) and allowability standards under Title I, Part A. o Training will emphasize cross-departmental accountability and the importance of accurate funding verification. o Attendance and training documentation will be retained for audit records. 4. Ongoing Monitoring and Quality Control o The Federal Programs Director, Payroll Director, Finance Director, and HR Director will jointly conduct quarterly monitoring reviews of payroll and personnel transactions charged to federal grants to verify allowability and compliance. o The reviews will include reconciliation of HR separation records, Payroll disbursements, and Federal Programs expenditure reports. o The first joint monitoring review will occur within 60 days of CAP approval. Responsible Parties: • Chief Financial Officer (CFO): Oversees reimbursement, approves policy updates, and ensures CAP implementation. • Finance Director: Verifies accurate cost classification, supports monitoring reviews, and ensures compliance with fiscal controls. • Federal Programs Director: Ensures compliance with federal allowability requirements and leads monitoring activities. • Payroll Supervisor: Confirms allowability of all payroll transactions before disbursement. • HR Director: Ensures accurate coding, separation documentation, and funding alignment for personnel actions. Completion Timeline: • Reimbursement: Within 30 days of CAP submission. • Policy and Procedure Revision: Within 45 days. • Training and Monitoring Implementation: Within 60 days. Verification of Implementation: Evidence of completion - including reimbursement documentation, revised policies and procedures, training records, and the first monitoring report - will be submitted to the auditor and TEA as required.
Name of Contact Person – Matt Flett, Chief Financial Officer Corrective Action Plan The District will immediately re-implement monthly personnel activity reports for employees with multiple funding sources and semi-annual certifications for staff 100% funded by a federal grant. Grant program manager...
Name of Contact Person – Matt Flett, Chief Financial Officer Corrective Action Plan The District will immediately re-implement monthly personnel activity reports for employees with multiple funding sources and semi-annual certifications for staff 100% funded by a federal grant. Grant program managers, building administrators, and federally funded staff will receive training to ensure compliance with 2 C.F.R. §200.430. Proposed Completion Date: February 2026
The Non-Profit Affiliate has secured a pre-development loan to reimburse the Authority in FY2026. Additionally, the COCC reimbursed over 50% of the amount due at 06/30/2025 to the Public Housing Programs in July 2025. The remaining funds are being paid down quarterly and will be paid off by end of F...
The Non-Profit Affiliate has secured a pre-development loan to reimburse the Authority in FY2026. Additionally, the COCC reimbursed over 50% of the amount due at 06/30/2025 to the Public Housing Programs in July 2025. The remaining funds are being paid down quarterly and will be paid off by end of FY2026.
FINDING 2025-001 Finding Subject: Annual Report Card, High School Graduation Rate – Special Test and Provisions Contact Person Responsible for Corrective Action: Marilyn Hampton, Supervisor of Student Services Contact Phone Number and Email Address: (219) 933-2461, ext.1048 mehampton@hammond.k12.in....
FINDING 2025-001 Finding Subject: Annual Report Card, High School Graduation Rate – Special Test and Provisions Contact Person Responsible for Corrective Action: Marilyn Hampton, Supervisor of Student Services Contact Phone Number and Email Address: (219) 933-2461, ext.1048 mehampton@hammond.k12.in.us Views of Responsible Officials: We concur with the finding and will implement a corrective action plan. Description of Corrective Action Plan: To ensure compliance with the requirements related to the grant agreement and the Special Test and Provisions Annual Report Card, High School Graduation rate compliance, the School City of Hammond will put into place an effective internal control system. The School City of Hammond will maintain an effective control system for withdrawals from each of the schools within the school system. At the time of withdrawal, a withdrawal form, along with a verified ID will be copied by the school’s registrar or designee. This withdrawal form must include the signatures of a parent and principal. This is the first step in the monitoring process. This system for withdrawals will also include placing a copy of the withdrawal form in the student information system (PowerSchool Attachments). The documentation that needs to be attached to the withdrawal form should include documents that show a Records Request, proof that the student withdrew to attend another school or educational program that results in the awarding of a high school diploma, has immigrated to another country, or is deceased. Upon completion of the withdrawal at the school, a copy of the documentation will be kept at the school, and the original documentation will be placed into the cumulative record. The school will forward a digital copy to Student Services. Upon receipt of the digital copy at Student Services, the administrator will review the file and will sign off to indicate that the record has been reviewed and is complete. To ensure this process is implemented with fidelity, training will take place on a yearly basis with administrators and office staff on the procedures that need to be followed during the withdrawal process. Anticipated Completion Date: 01/31/2026
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