Corrective Action Plans

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Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken Staff Training Quality Assurance ...
Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken Staff Training Quality Assurance and Monitoring To ensure sustained compliance, the organization is implementing the following monitoring process: • Monthly random chart audits of sliding fee documentation. • Minimum sample size of 40 patient records • Audit elements will include: o Income documentation present o Household size documented o Correct FPG calculation o Correct discount level applied • Findings will be reported to senior leadership and the compliance committee. Corrective coaching is provided when deficiencies are identified. Comprehensive training is being conducted for all relevant staff including: • Patient access / front desk staff • Financial counselors • Billing staff • Site managers Training topics include: • HRSA Sliding Fee Discount Program requirements • Determining household size • Calculating FPG percentage • Acceptable income documentation • Proper EHR documentation • Self-attestation procedures
Views of Responsive Officials of Auditee: In the past year we have developed a written policy and procedure manual over procurement. We will ensure that this manual is updated in a reasonable amount of time to ensure all applicable policies are addressed. With our increasing federal grant funding th...
Views of Responsive Officials of Auditee: In the past year we have developed a written policy and procedure manual over procurement. We will ensure that this manual is updated in a reasonable amount of time to ensure all applicable policies are addressed. With our increasing federal grant funding this is a high priority for the City.
Visit Baltimore, Inc. and Subsidiary has implemented procedures to reconcile the federal award subsidiary ledger to the general ledger prior to submission of monthly performance reports. Additional review controls have been established to ensure reported expenditures agree to the underlying accounti...
Visit Baltimore, Inc. and Subsidiary has implemented procedures to reconcile the federal award subsidiary ledger to the general ledger prior to submission of monthly performance reports. Additional review controls have been established to ensure reported expenditures agree to the underlying accounting records.
Visit Baltimore, Inc. and Subsidiary has adopted written procurement, suspension and debarment policies in accordance with 2 CFR requirements. Procedures have been implemented to verify and document contractor eligibility through the System for Award Management (SAM) prior to engagement to ensure on...
Visit Baltimore, Inc. and Subsidiary has adopted written procurement, suspension and debarment policies in accordance with 2 CFR requirements. Procedures have been implemented to verify and document contractor eligibility through the System for Award Management (SAM) prior to engagement to ensure ongoing compliance.
Condition - The District did not comply with the reporting requirements with respect to filing accurate quarterly reports with the ISBE. Plan - The District will submit accurate expenditure reports in the future regarless of the project end date. Anticipated Date of Completion - July 1, 2026; Name o...
Condition - The District did not comply with the reporting requirements with respect to filing accurate quarterly reports with the ISBE. Plan - The District will submit accurate expenditure reports in the future regarless of the project end date. Anticipated Date of Completion - July 1, 2026; Name of Contact Person - Dr. Beau Fretueg, Superintendent; Management Response - We will review grant expenditures on a quarterly basis and submit accurate expenditure reports to the ISBE as required.
Condition - The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan - A second person (Superintendent) compares the meal counts in the claim to: the SDS daily meal...
Condition - The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan - A second person (Superintendent) compares the meal counts in the claim to: the SDS daily meal count reports, monthly participation summary, eligibility rosters (free, reduced, paid) and USDA reimbursement rates. The reviewer will then sign and date a reconciliation sheet before submission. Anticipated Date of Completion - July 1, 2026; Name of Contact Person - Dr. Beau Fretueg, Superintendent; Management Response - The corrective action plan was discussed with the employee responsible for filing the claim, the business manager, and the superintendent. After discussion, the plan was approved by the superintendent.
DEPARTMENT OF THE TREASURY Coronovirus State and Local Fiscal Recovery Funds -Assistance Listing No. 21.027 Recommendation: We recommend that the Town implement stronger internal controls over federal reporting, including establishing a formal reconciliation process between the general ledger and th...
DEPARTMENT OF THE TREASURY Coronovirus State and Local Fiscal Recovery Funds -Assistance Listing No. 21.027 Recommendation: We recommend that the Town implement stronger internal controls over federal reporting, including establishing a formal reconciliation process between the general ledger and the Project and Expenditure Report, requiring Town Administrator's review and approval of all federal reports prior to submission, and providing additional training to staff on Federal reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town will strengthen its reconciliation procedures requiring the Director of Finance to reconcile all federal expenditures reported in the Project and Expenditure report to the general ledger. Name of the contact person responsible for corrective action: Kelly Baldwin, Director of Finance Planned completion date for corrective action plan: April 1, 2026.
The district acknowledges this finding. East Marshall operates with a small administrative and financial staff but we will continue to have segregation of duties as a priority.
The district acknowledges this finding. East Marshall operates with a small administrative and financial staff but we will continue to have segregation of duties as a priority.
Finding Number: 2024-001 Planned Corrective Action: The fixed asset in question was inadvertently coded from a supply account. The asset subsequently was not picked up on the pending fixed asset report. Therefore, it did not get recorded to the Equipment Inventory System until it was reported to the...
Finding Number: 2024-001 Planned Corrective Action: The fixed asset in question was inadvertently coded from a supply account. The asset subsequently was not picked up on the pending fixed asset report. Therefore, it did not get recorded to the Equipment Inventory System until it was reported to the Treasurer by the Auditor of State. Moving forward, the Treasurer will scrutinize all purchases for the proper object coding to ensure fixed assets are reporting properly. The Treasurer will also review all purchases for the possibility of posting to the Equipment Inventory System. Anticipated Completion Date: 03/11/2026 Responsible Contact Person: Bruce Steenrod
Management concurs with and accepts the material weakness in its internal control. We believe it is cost-efficient to continue to rely on external auditors to assist in the preparation of its financial statements and related notes, including the schedule of expenditures of federal awards.
Management concurs with and accepts the material weakness in its internal control. We believe it is cost-efficient to continue to rely on external auditors to assist in the preparation of its financial statements and related notes, including the schedule of expenditures of federal awards.
Finding 2025-004 Name of Responsible Individuals: Mrs. Tiffany Grandy, Assistant Director of Financial Aid, Mr. Jared Peterson, Financial Aid Counselor, Mrs. Terri Grice, Associate Registrar, and Mrs. Vicky Warrick, Registrar Corrective Action: As a result of Audit Finding 2025-004, Financial Aid ha...
Finding 2025-004 Name of Responsible Individuals: Mrs. Tiffany Grandy, Assistant Director of Financial Aid, Mr. Jared Peterson, Financial Aid Counselor, Mrs. Terri Grice, Associate Registrar, and Mrs. Vicky Warrick, Registrar Corrective Action: As a result of Audit Finding 2025-004, Financial Aid has generated a report specifically for the Registrar’s Office that indicates enrollment plans for students who stop attending or withdraw from all courses for a single semester. The Registrar’s Office will be using this report for reporting enrollment status changes for students via NSLDS. Anticipated Completion Date: March 19, 2026
Finding 2025-003 Name of Responsible Individuals: Mrs. Tiffany Grandy, Assistant Director of Financial Aid and Mr. Jared Peterson, Financial Aid Counselor Corrective Action: As a result of Audit Finding 2025-003, Financial Aid will originate direct loans at least one week prior to the scheduled disb...
Finding 2025-003 Name of Responsible Individuals: Mrs. Tiffany Grandy, Assistant Director of Financial Aid and Mr. Jared Peterson, Financial Aid Counselor Corrective Action: As a result of Audit Finding 2025-003, Financial Aid will originate direct loans at least one week prior to the scheduled disbursement date. For large origination files at semester starts, financial aid administrators will run simulation originations to work through origination and/or disbursement rejections prior to sending real originations at least one month prior to semester starts. Anticipated Completion Date: March 19, 2026
Finding 2025-002 Name of Responsible Individuals: Mrs. Tiffany Grandy, Assistant Director of Financial Aid and Mr. Jared Peterson, Financial Aid Counselor Corrective Action: As a result of Audit Finding 2025-002, Financial Aid will use a daily credit change report generated automatically from academ...
Finding 2025-002 Name of Responsible Individuals: Mrs. Tiffany Grandy, Assistant Director of Financial Aid and Mr. Jared Peterson, Financial Aid Counselor Corrective Action: As a result of Audit Finding 2025-002, Financial Aid will use a daily credit change report generated automatically from academic records to make any manual credit updates in the PowerFAIDS financial system. Additionally, Financial Aid will use selection sets within PowerFAIDS to identify any credit hour mismatches between what is manually reported versus what is integrated from Power Campus, the academic records database. Anticipated Completion Date: March 19, 2026
Finding 2025-001 Name of Responsible Individuals: Mrs. Tiffany Grandy, Assistant Director of Financial Aid, Mr. Jared Peterson, Financial Aid Counselor, and Mrs. Laurie Evans, Assistant Controller Corrective Action: As a result of Audit Finding 2025-001, Financial Aid and the Controller's Office con...
Finding 2025-001 Name of Responsible Individuals: Mrs. Tiffany Grandy, Assistant Director of Financial Aid, Mr. Jared Peterson, Financial Aid Counselor, and Mrs. Laurie Evans, Assistant Controller Corrective Action: As a result of Audit Finding 2025-001, Financial Aid and the Controller's Office continues to implement a bi-weekly reconciliation process to ensure that any excess funds are disbursed or returned via G5 within the 10-day window. The Controller’s Office has updated reporting practices that ensure that return of funds are appropriately notated as return of Title IV funds. Anticipated Completion Date: March 19, 2026
Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: We recommend that the University verifies the enrollment intensity for each student receiving the Federal Pell Grant prior to finalizing their award package. Explanation of disagreement with audit finding: There is no disa...
Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: We recommend that the University verifies the enrollment intensity for each student receiving the Federal Pell Grant prior to finalizing their award package. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University is working with a PowerFAIDS consultant to ensure that the correct number of credits populates based on the courses inputted. The issue has also been added to their procedures to check the Class Load and Credits field whenever packaging or revising a student’s aid. Name(s) of the contact person(s) responsible for corrective action: Michael Moos, Vice President of Finance Planned completion date for corrective action plan: June 30, 2026
To: U.S. Department of the Treasury Northeast Iowa Mental Health Center respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Hacker, Nelson & Co., CPAs, 123 W. Water Street, Decorah, IA 52101 Audit period:...
To: U.S. Department of the Treasury Northeast Iowa Mental Health Center respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Hacker, Nelson & Co., CPAs, 123 W. Water Street, Decorah, IA 52101 Audit period: Year ended June 30, 2025 The finding from the June 30, 2025 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING - FEDERAL AWARDS PROGRAM AUDIT. U.S. Department of the Treasury: Internal control deficiency: Federal Assistance Listing Number 93.696 Certified Community Behavioral Health Clinic Expansion Grants Internal control deficiency: See Finding 2025-001 Recommendation: We realize that with a limited number of office employees, segregation of duties is difficult. However, the Center should review the operating procedures to obtain the maximum internal control possible under the circumstances. The Center should also consider the potential consequence of reliance on one person for financial, grant and payroll reporting. Action Taken: This issue is reviewed annually through the audit review with the Board of Directors. The Center has implemented a segregation of duties action plan effective June 30, 2025 to address this issue going forward. Anticipated Date of Completion: June 30, 2026. In the U.S. Department of the Treasury have questions regarding this plan, please call Bonnie Johnson, MIS Director, at 563-382-3649. Sincerely yours, (signed Bonnie Jonson), Bonnie Johson Northeast Iowa Mental Health Center MIS Director cc: Brent V Berns, CPA
Audit Finding Reference: 2025-001 Planned Corrective Action: The City will implement formal policies and procedures regarding separation of duties and the requirement of a second individual being involved in the reporting process. This year was atypical due to staff turnover, which impacted normal o...
Audit Finding Reference: 2025-001 Planned Corrective Action: The City will implement formal policies and procedures regarding separation of duties and the requirement of a second individual being involved in the reporting process. This year was atypical due to staff turnover, which impacted normal operations. Planned Implementation Date of Corrective Action: Immediate Person Responsible for Corrective Action: Marisa Batista, CFO
Finding Number: 2025-001 Federal Agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance Listing #: 84.063 & 84.007 Award Year: 2025 Corrective Action Plan: Berkshire Community college agrees with this finding, and upon its review of the affected students and t...
Finding Number: 2025-001 Federal Agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance Listing #: 84.063 & 84.007 Award Year: 2025 Corrective Action Plan: Berkshire Community college agrees with this finding, and upon its review of the affected students and the college’s policies and procedures. The Student Financial Services Office will work with the Registrar and use reports delivered by Institutional Effectiveness to monitor and determine withdrawals on a regular basis. Timeline for Implementation of Corrective Action Plan: Immediately Contact Person: Karrie Trautman, Director of Financial aid
FINDING 2025-003 (Auditor Assigned Reference Number) Finding Subject: Education Stabilization Fund – Equipment and Real Property Management Contact Person Responsible for Corrective Action: Stefanie Grandstaff, Director of Business Services Contact Phone Number and Email Address: stefanie.grandstaff...
FINDING 2025-003 (Auditor Assigned Reference Number) Finding Subject: Education Stabilization Fund – Equipment and Real Property Management Contact Person Responsible for Corrective Action: Stefanie Grandstaff, Director of Business Services Contact Phone Number and Email Address: stefanie.grandstaff@epulaski.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: The Director of Business Services will add the missing asset to spreadsheet used for tracking equipment purchased with federal funds. She will also ensure that all required fields are included and properly completed on the spreadsheet. Anticipated Completion Date: February 28, 2026
FINDING 2025-002 (Auditor Assigned Reference Number) Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Stefanie Grandstaff, Director of Business Services Contact Phone Number and Email Address: stefanie.grandstaff@epulaski.k12.in.us Views of Res...
FINDING 2025-002 (Auditor Assigned Reference Number) Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Stefanie Grandstaff, Director of Business Services Contact Phone Number and Email Address: stefanie.grandstaff@epulaski.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: The Food Service Director will continue uploading the state-provided file into Skyward and verifying the accuracy of the imported information. After this review, the Food Service Director will notify the Director of Business Services via email to independently confirm that the data from the state file was uploaded and processed correctly in Skyward. This email correspondence will serve as documentation of the verification process. In addition, we will address the issue related to the 30-day rollover and students who withdraw. We will work with Skyward to adjust system parameters so that both active and inactive students are included, ensuring the rollover is accurate. The Food Service Director will also review each newly enrolled student to confirm the eligibility status by verifying whether a parent submitted an application through the school or the state. Based on the documentation available, she will update eligibility status as needed and then email the Director of Business Services to review and confirm accuracy. Anticipated Completion Date: June 30, 2026.
Finding 2025-01 Condition: The school’s procurement files did not contain documentation regarding competitive procurement procedures for one contract. Corrective Action Planned: Comply with federal procurement regulations by setting up a quote system and seek quotes for anticipated spending of over ...
Finding 2025-01 Condition: The school’s procurement files did not contain documentation regarding competitive procurement procedures for one contract. Corrective Action Planned: Comply with federal procurement regulations by setting up a quote system and seek quotes for anticipated spending of over $10,000. Anticipated Completion Date: Complete Contact: Marie Znamierowski, Director of Business Operations
District inventory management is governered by Board Policy DID: Inventories, which instructs the Chief Financial Officer to create inventory procedures. After this finding was identified in 2024 Schedule of Findings, a cross-functional work group draft an operational procedure for inventory, incorp...
District inventory management is governered by Board Policy DID: Inventories, which instructs the Chief Financial Officer to create inventory procedures. After this finding was identified in 2024 Schedule of Findings, a cross-functional work group draft an operational procedure for inventory, incorporating the feedback of Academics, Finance, and Operation. The procedure is now included in the Procure to Pay Manual and will be considered fro annual madatory finance training .
Finding No. 2025-004: Reporting AL No.: 12.600 Program Title: Community Investment Grant Award Number: HQ00052310045 Condition During our audit, we tested a non-statistical sample of one subaward and found that the reporting required by Section 2, Full Disclosure of Entities Receiving Federal Fundin...
Finding No. 2025-004: Reporting AL No.: 12.600 Program Title: Community Investment Grant Award Number: HQ00052310045 Condition During our audit, we tested a non-statistical sample of one subaward and found that the reporting required by Section 2, Full Disclosure of Entities Receiving Federal Funding, of the Federal Funding Accountability and Transparency Act (“FFATA”) was not completed at all. Corrective Action Plan The Department of Hawaiian Home Lands (“DHHL”) will change internal grants administrative procedures to better account for the submittal of the FFATA and the requirements of 2 CFR Part 170, Appendix A. A report will be submitted to the Federal Funding Accountability and Transparency Act Subaward Reporting System by February 28, 2026. Person Responsible Lilliane Makaila, Acting Planning Program Manager Anticipated Date of Completion The FFATA report will be submitted by February 28, 2026.
Finding No. 2025-003: Subrecipient Monitoring AL No.: 11.029 Program Title: Tribal Broadband Connectivity Program Grant Award Number: NT23TBC0290054 Condition Subaward agreements did not include certain required federal award information. A risk assessment was not performed for the subrecipient prio...
Finding No. 2025-003: Subrecipient Monitoring AL No.: 11.029 Program Title: Tribal Broadband Connectivity Program Grant Award Number: NT23TBC0290054 Condition Subaward agreements did not include certain required federal award information. A risk assessment was not performed for the subrecipient prior to execution of the subaward agreement. No evidence of pass-through entity verifying that subrecipients are audited as required by 2 CFR Section 200, Subpart F. DHHL failed to communicate five required pieces of award information to the subrecipient (UH) as mandated by 2 CFR 200.332(a)(1), including: Subrecipient’s unique entity identifier, Subaward Budget Period Start and End Date, Assistance Listing Number (12.017), Identification of whether the award is R&D, Indirect cost rate information (including de minimis rate status). Corrective Action Plan DHHL will implement the following corrective actions to address the identified issues to align subrecipient monitoring in compliance with 2 CFR 200. Subaward and Documentation Corrections: DHHL will review the original federal award and UH agreement, then prepare subaward amendments incorporating all required elements under 2 CFR 200.332(a)(1). DHHL will also obtain UH’s UEI and confirm and document the subaward budget period and assistance listing number. DHHL will also assure all amendments and documents obtain NTIA/NIST approval for any required federal documentation. Risk Assessment and Monitoring: DHHL will conduct and document risk assessment for UH in accordance with 2 CFR 200.332(b). DHHL will then use the risk assessment to determine the appropriate level of subrecipient monitoring. Moving forward, DHHL will integrate the risk assessment requirement prior to any subaward execution. Audit Verification and Compliance: DHHL will verify UH’s single audit status, review and document UH’s Single Audit Report to assess and establish annual monitoring/management procedures. DHHL will implement the same processes for future subrecipients moving forward. Systematic Improvements and Training: DHHL will develop a subaward checklist and standardized subaward template aligned with 2 CFR 200.332 requirements. DHHL plans to implement mandatory compliance and legal review prior to subaward execution. Person Responsible Jaren Tengan, Broadband Coordinator And/or Aislen Bacalso, Broadband Coordination Assistant Anticipated Date of Completion The updated documentation is subject to the completion and approval of Federal Budget Amendments. DHHL is hopeful that NTIA and NIST will provide feedback and approval by June 2026, and DHHL will immediately prepare and submit any additional subaward documentation for the UH Subaward. (Please note this is the first fiscal year DHHL is working with NIST. It is unsure how long budget amendment processes will take.)
Finding No. 2025-002: Reporting AL No.: 11.029 Program Title: Tribal Broadband Connectivity Program Grant Award Number: NT23TBC0290054 Condition FFATA report was not filed regarding the UH Subaward for FY 2025 (7/1/2024–6/30/2025). Corrective Action Plan DHHL will work on budget amendments on the Fe...
Finding No. 2025-002: Reporting AL No.: 11.029 Program Title: Tribal Broadband Connectivity Program Grant Award Number: NT23TBC0290054 Condition FFATA report was not filed regarding the UH Subaward for FY 2025 (7/1/2024–6/30/2025). Corrective Action Plan DHHL will work on budget amendments on the Federal side via eRA Commons (with NTIA and NIST oversight). Once Budget amendments are made, DHHL will immediately prepare and submit FFATA report for UH subaward, make additional updates on .gov systems for report submission, and document reason for late submission. DHHL will confirm UH subaward meets FFATA reporting threshold ($30,000 for subawards) and review all other active subawards for FFATA reporting requirements. Moving forward, DHHL will establish procedures for timely FFATA and subaward reporting. DHHL will also review all subawards from past two years for missed FFATA reports and file any additional delinquent reports. Person Responsible Jaren Tengan, Broadband Coordinator And/or Aislen Bacalso, Broadband Coordination Assistant Anticipated Date of Completion The updated reports are subject to the completion and approval of Federal Budget Amendments. DHHL is hopeful that NTIA and NIST will provide feedback and approval by June 2026, and DHHL will immediately prepare and submit FFATA reports for the UH subaward. (Please note this is the first fiscal year DHHL is working with NIST. It is unsure how long budget amendment processes will take.)
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