Corrective Action Plans

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Panthera continued strengthening its internal controls through 2025 and early 2026 by expanding its use of Rippling to support more consistent HR workflows, documentation, and approval tracking. We also transitioned portions of our international workforce from DEEL to Safeguard, which offers stronge...
Panthera continued strengthening its internal controls through 2025 and early 2026 by expanding its use of Rippling to support more consistent HR workflows, documentation, and approval tracking. We also transitioned portions of our international workforce from DEEL to Safeguard, which offers stronger compliance monitoring and country‑specific employment controls. This shift enhances our ability to maintain complete personnel files, ensure accurate payroll processing, and meet federal requirements for allowability of labor costs. In addition, the new timesheet module implemented across 2024–2025 continues to improve documentation of personnel activity and verification of payroll‑related charges. The organization also experienced a leadership transition with the departure of our CAO in late 2025 and the onboarding of a new Chief People Officer in early 2026. This change has brought renewed focus to HR governance, process standardization, and long‑term workforce planning, further reinforcing Panthera’s commitment to strong internal controls over federal expenditures.
Recommendation: We recommend the Human Services Department review procedures established for contract review and identify the procedures responsible for monitoring spending on provider contracts. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action planne...
Recommendation: We recommend the Human Services Department review procedures established for contract review and identify the procedures responsible for monitoring spending on provider contracts. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action planned in response to finding: Management has established procedures for monitoring and reviewing provider contract spending. Name(s) of the contact person(s) responsible for corrective action: Melissa Diener, Assistant Finance Director Planned completion date for corrective action plan: The County immediately began evaluating procedures and will implement as soon as possible.
Recommendation: We recommend the Human Services Department develop a uniform payroll allocation process that will allocate all employee costs to each program based on actual hours worked, including fiscal and administrative employees. They should also implement a uniform account structure that inclu...
Recommendation: We recommend the Human Services Department develop a uniform payroll allocation process that will allocate all employee costs to each program based on actual hours worked, including fiscal and administrative employees. They should also implement a uniform account structure that includes the objects necessary to track program costs, so they can be used to accurately calculate and report costs in accordance with all program requirements. In addition, the Department should redesign its accounting, reporting and reconciliation structure to include all programs and prevents double reporting from happening. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action planned in response to finding: Management has begun a review of the Human Services Department payroll allocation process. Name(s) of the contact person(s) responsible for corrective action: Melissa Diener, Assistant Finance Director Planned completion date for corrective action plan: The County has begun evaluating procedures and will implement as soon as possible.
Recommendation: We recommend the County conduct a review of its overall account structure, and the Finance Department should coordinate and assist the Human Services Department in the implementation of a new, uniform account structure. The Human Services Department should develop a uniform payroll a...
Recommendation: We recommend the County conduct a review of its overall account structure, and the Finance Department should coordinate and assist the Human Services Department in the implementation of a new, uniform account structure. The Human Services Department should develop a uniform payroll allocation process that will allocate all employee costs to each program based on actual hours worked, regardless of funding availability. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action planned in response to finding: Management has begun a review of the Human Services Department account structure. Name(s) of the contact person(s) responsible for corrective action: Melissa Diener, Assistant Finance Director Planned completion date for corrective action plan: The County immediately has begun evaluating procedures and will implement as soon as possible.
Corrective Action Plan The Town has established and maintains effective internal controls over compliance with federal requirements that have a direct and material effect on federal programs. To accomplish this, the Town has implemented the practice of dual control for federal grant expenditure repo...
Corrective Action Plan The Town has established and maintains effective internal controls over compliance with federal requirements that have a direct and material effect on federal programs. To accomplish this, the Town has implemented the practice of dual control for federal grant expenditure reporting. One individual will prepare the expenditure report, while a separate, knowledgeable individual will review the report before it is submitted. For our ARPA expenditure report ending on 3/31/26, the Finance Director prepared the report and the Town Manager approved it. Name of Contact and Completion Date Matt Mannino Finance Director 603-792-1313 mmannino@bedfordnh.gov Implementation Date: October 31, 2025
Management agrees with the finding and will enhance existing reporting procedures to require documented evidence of review and approval for reports submitted to grantors. Macdonald Center dba Maybelle Center will retain documentation of supervisory review and approval as part of its grant compliance...
Management agrees with the finding and will enhance existing reporting procedures to require documented evidence of review and approval for reports submitted to grantors. Macdonald Center dba Maybelle Center will retain documentation of supervisory review and approval as part of its grant compliance files going forward.
The BoatU.S. ADVs contract will be amended for fiscal year 2026 contracts to include the ALN, and the need for a Single Audit for subrecipients that expend over $1,000,000 in federal funding in their given fiscal year. BoatU.S. will implement stricter deadlines for subrecipients to submit their bian...
The BoatU.S. ADVs contract will be amended for fiscal year 2026 contracts to include the ALN, and the need for a Single Audit for subrecipients that expend over $1,000,000 in federal funding in their given fiscal year. BoatU.S. will implement stricter deadlines for subrecipients to submit their biannual reports in 2026. Progress monitoring will be done throughout the year and documented by BoatU.S. personnel. This should also include project cost documentation of the subrecipient is used for authorized purposes. These reports may need to include photos of the tasks completed, if necessary. BoatU.S. plans to only reimburse for progress costs as incurred by the subrecipient.
Corrective Action Plan (CAP) a) Actions Planned in Response to the Finding: The Organization has determined the benefit of adequately segregating duties is less than the cost. Based on this assessment, the Organization is accepting the risk posed by the deficiency while also evaluating mitigating co...
Corrective Action Plan (CAP) a) Actions Planned in Response to the Finding: The Organization has determined the benefit of adequately segregating duties is less than the cost. Based on this assessment, the Organization is accepting the risk posed by the deficiency while also evaluating mitigating controls that will help reduce the risk of material misstatement of the financial statements. Management is attempting to mitigate the associated risks by doing the following: 1. Identifying areas lacking segregation of duties and where there are higher risks of fraud occurring. 2. Implementing limited segregation to the extent possible to reduce risks without impairing efficiency. 3. Using the knowledge of management and the Board to review accounting records and reports, b) Official Responsible for Ensuring Corrective Action: Brenda Schmitz, Property Manager, will monitor the effectiveness of the above actions and make changes as considered appropriate. c) Planned Completion Date for the Corrective Action: The corrective action plan for this finding will be completed by December 31, 2026. d) Explanation of Disagreement: There is no disagreement with the audit finding. e) Plan to Monitor Completion of Corrective Action: The Board will be monitoring this corrective action plan to review the recommendations and take appropriate action.
Corrective Action Plan (CAP) f) Actions Planned in Response to the Finding: The Organization does not plan to take any action but is aware of the condition. Based on the cost of correcting this deficiency, the Organization has decided to accept the risk associated with this deficiency. g) Official R...
Corrective Action Plan (CAP) f) Actions Planned in Response to the Finding: The Organization does not plan to take any action but is aware of the condition. Based on the cost of correcting this deficiency, the Organization has decided to accept the risk associated with this deficiency. g) Official Responsible for Ensuring Corrective Action: Brenda Schmitz, Property Manager, will review the financial statements and related footnotes and approve them. h) Planned Completion Date for the Corrective Action: The corrective action plan for this finding will be completed by December 31, 2026. i) Explanation of Disagreement: There is no disagreement with the audit finding. j) Plan to Monitor Completion of Corrective Action: The Board will be monitoring this corrective action plan.
Corrective Action Plan (CAP) a) Actions Planned in Response to the Finding: The Organization will review and approve adjusting journal entries as proposed by the auditor, as well as taking responsibility for the audited financial statements. b) Official Responsible for Ensuring Corrective Action: Br...
Corrective Action Plan (CAP) a) Actions Planned in Response to the Finding: The Organization will review and approve adjusting journal entries as proposed by the auditor, as well as taking responsibility for the audited financial statements. b) Official Responsible for Ensuring Corrective Action: Brenda Schmitz, Property Manager, will review the adjusting journal entries and approve them. c) Planned Completion Date for the Corrective Action: The corrective action plan for this finding will be completed by December 31, 2026. d) Explanation of Disagreement: There is no disagreement with the audit finding. e) Plan to Monitor Completion of Corrective Action: The Board will be monitoring this corrective action plan.
Noncompliant Buy America Procurements - Transit - MDT - The Montana Department of Transportation is strengthening internal controls and ensuring full compliance with federal requirements for procuring public transit vehicles. The Transit Section and the Procurement Unit are jointly developing compre...
Noncompliant Buy America Procurements - Transit - MDT - The Montana Department of Transportation is strengthening internal controls and ensuring full compliance with federal requirements for procuring public transit vehicles. The Transit Section and the Procurement Unit are jointly developing comprehensive procedures that clearly define roles and responsibilities, update procurement checklists, and establish a centralized location for maintaining complete procurement files. Responsible Party - Kimberly Doherty, Accounting Systems Supervisor, Montana Department of Transportation Target Implementation Date - 12/31/2026
Noncompliant Eligibility Determinations - Literacy - OPI - The Montana Office of Public Instruction concurs with this finding. This issue was addressed in the prior audit. The grant ended shortly after completion of that audit, and there was no opportunity to change awarded amounts once the issue wa...
Noncompliant Eligibility Determinations - Literacy - OPI - The Montana Office of Public Instruction concurs with this finding. This issue was addressed in the prior audit. The grant ended shortly after completion of that audit, and there was no opportunity to change awarded amounts once the issue was identified. The previous superintendent agreed not to pull funds back. The matter has been corrected in the new grant that began in October 2024, and the issue does not appear to affect the new grant. Mechanisms have been implemented to ensure that only schools meeting eligibility requirements receive funds. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026
Inadequate Support for Federal Reimbursement - Literacy - OPI - The Montana Office of Public Instruction partially concurs with this finding. The prior audit was not completed in time for the Office to implement changes before the fiscal years reviewed in the current audit. The Office implemented mo...
Inadequate Support for Federal Reimbursement - Literacy - OPI - The Montana Office of Public Instruction partially concurs with this finding. The prior audit was not completed in time for the Office to implement changes before the fiscal years reviewed in the current audit. The Office implemented more stringent criteria for cash requests from schools in late 2024, and these requirements have been in place since that time. Although there has been considerable pushback from local education agencies due to the added burden, the Office has remained firm on the information required. Cash requests are audited quarterly by the Internal Control Auditor against submitted budget documents, and any issues identified are addressed. The more stringent criteria are fully implemented, and no further corrective actions are needed beyond continuing the current process. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026
Inadequate Cash Management Controls - Various - DPHHS - The Montana Department of Public Health and Human Services implemented initial changes to its cash draw processes in state fiscal year 2025 and was in the process of implementing additional controls during a period of concurrent change in feder...
Inadequate Cash Management Controls - Various - DPHHS - The Montana Department of Public Health and Human Services implemented initial changes to its cash draw processes in state fiscal year 2025 and was in the process of implementing additional controls during a period of concurrent change in federal award administration (DOGE) and in state accounting policy. Gaps and inconsistencies in internal controls occurred during that transition. The department fully implemented revised cash draw processes and enhanced internal controls in August 2026 and will monitor the interval between drawdown and disbursement as part of its ongoing internal control monitoring. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 8/21/2026
Inadequate Supporting Documentation for Local Agency Costs - WIC - DPHHS - The Montana Department of Public Health and Human Services does not concur because the recommendations would require receipt level documentation for every subrecipient transaction, which federal regulation does not require, a...
Inadequate Supporting Documentation for Local Agency Costs - WIC - DPHHS - The Montana Department of Public Health and Human Services does not concur because the recommendations would require receipt level documentation for every subrecipient transaction, which federal regulation does not require, and because the department’s existing monitoring framework meets the requirements of 2 CFR 200.332. Paragraph citations in this response refer to the Uniform Guidance as revised effective October 1, 2024; for awards issued before that date, the corresponding provisions are 2 CFR 200.332(b), (d), and (e). Under 2 CFR 200.332(c), a pass‑through entity must evaluate each subrecipient’s risk of noncompliance and risk of fraud to determine the appropriate level of subrecipient monitoring. Under 2 CFR 200.332(e), the required monitoring activities include reviewing financial and performance reports, following up on deficiencies and ensuring the subrecipient takes timely and appropriate action, and issuing management decisions on audit findings. Under 2 CFR 200.332(f), additional tools such as training and technical assistance, on‑site reviews, and agreed‑upon procedures engagements may be used depending on the risk assessment. The regulation does not require transaction level or receipt level documentation for all subrecipient expenditures as a condition of reimbursement. The department acknowledges that the auditors identified expenditures for which receipt‑level support was not on file at the time of review. The department’s position is that the controls described above, rather than universal receipt‑level retention, are the level of monitoring 2 CFR 200.332 requires given the risk profile of the Women, Infants, and Children (WIC) local agency network, and that the department retains the documentation it obtains when additional support is requested. Based on the department’s understanding of the audit results, the auditors did not report any unallowable costs during their review, and their finding focused solely on whether every cost was fully supported by receipt‑level documentation. Extending receipt‑level submission and retention to every expenditure would add substantial administrative work for the department and its local agencies without a corresponding improvement in the department’s ability to detect unallowable costs, which the existing expense report review and biennial on‑site review already address. For these reasons, the department does not concur with the recommendations. As provided in 2 CFR 200.511(c), the discussion above is the department’s detailed explanation of why it believes the recommended corrective action is not required. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - N/A
Noncompliant Rebate Calculation Review Controls - WIC - DPHHS - The Montana Department of Public Health and Human Services implemented a documentation tracking system and updated its procedures to require a documented review before invoicing. The department also retroactively reviewed and documented...
Noncompliant Rebate Calculation Review Controls - WIC - DPHHS - The Montana Department of Public Health and Human Services implemented a documentation tracking system and updated its procedures to require a documented review before invoicing. The department also retroactively reviewed and documented all rebate calculations for fiscal year 2026. The department completed this corrective action in May 2026. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 5/15/2026
Inadequate Control Over Federal Reporting - UI - DLI - The Montana Department of Labor and Industry resolved the control deficiencies related to the Employment and Training Administration (ETA) Forms 191, 9050, and 9052 through the modernization of the Unemployment Insurance system, which replaced t...
Inadequate Control Over Federal Reporting - UI - DLI - The Montana Department of Labor and Industry resolved the control deficiencies related to the Employment and Training Administration (ETA) Forms 191, 9050, and 9052 through the modernization of the Unemployment Insurance system, which replaced the Montana Integrated System to Improve Customer Service (MISTICS) with the Montana Unemployment Services Environment (MUSE). The new MUSE system became operational in October 2023, after the July through September 2023 reporting period covered by the finding. The department has also updated its procedures to ensure supervisory reviews and approvals are consistently documented and retained. Approval emails are now saved in monthly electronic shared files. Centralized retention in these shared files provides access to authorized staff, supports reported data, and reduces the risk of documentation being unavailable due to staff turnover or loss of individual records. Responsible Party - Robin Graham, Central Services Division Administrator, Montana Department of Labor and Industry Target Implementation Date - 12/31/2026
Inadequate Support for Benefit Accuracy Measurement Reviews - UI - DLI - The Montana Department of Labor and Industry began retaining copies of the on-demand report generated from the Sun System upon learning of the concern. This process continued until October 2024, when staff confirmed that the ne...
Inadequate Support for Benefit Accuracy Measurement Reviews - UI - DLI - The Montana Department of Labor and Industry began retaining copies of the on-demand report generated from the Sun System upon learning of the concern. This process continued until October 2024, when staff confirmed that the newly developed view in the Montana Unemployment System Enhancement (MUSE) system was functioning as intended. The MUSE system now includes a real-time interface that compares its data with the Sun System, providing staff with immediate information to monitor the volume of items selected for workload sampling. Responsible Party - Robin Graham, Central Services Division Administrator, Montana Department of Labor and Industry Target Implementation Date - 12/31/2026
Inaccurate Federal Reporting - UI - DLI - The Montana Department of Labor and Industry has made several revisions to the Employment and Training Administration (ETA) 2112 preparation and reconciliation process. Additional notations have been added to the existing ETA 2112 preparation workbook, along...
Inaccurate Federal Reporting - UI - DLI - The Montana Department of Labor and Industry has made several revisions to the Employment and Training Administration (ETA) 2112 preparation and reconciliation process. Additional notations have been added to the existing ETA 2112 preparation workbook, along with screenshots to assist the preparer with accuracy. Unemployment Insurance transactional tasks have been re-assigned to the appropriate accounting and budgeting staff to improve workflow. An additional separate but collaborative bank-to-SABHRS reconciliation has been incorporated into the process. Monthly Unemployment Insurance process meetings have been reinstated for all staff who perform tasks that impact the preparation and reconciliation of the ETA 2112 report. The purpose of these meetings is to discuss any issues regarding the process and to check in on the completion of the report and its components. The department will be engaging with a sister state that uses the same vendor software for its Unemployment Insurance system in an information-sharing session. The designated state has staff experienced in ETA 2112 preparation and submission, and department staff hope to confirm that the system report utilized in the process reflects accurate data. The department has also re-engaged a previously procured vendor to conduct a reporting accuracy and efficiency assessment of the Unemployment Insurance Program. Responsible Party - Robin Graham, Central Services Division Administrator, Montana Department of Labor and Industry Target Implementation Date - 12/31/2026
Inadequate Supporting Documentation - Title 1 - OPI - The Montana Office of Public Instruction partially concurs with this finding. The prior audit was not completed in time for the Office to implement changes before the fiscal years reviewed in the current audit. More stringent criteria for cash re...
Inadequate Supporting Documentation - Title 1 - OPI - The Montana Office of Public Instruction partially concurs with this finding. The prior audit was not completed in time for the Office to implement changes before the fiscal years reviewed in the current audit. More stringent criteria for cash requests from schools were put in place in late 2024, and these requirements have been followed since that time. Although there was considerable pushback from local education agencies, the Office remained firm on the information required. The Office audits cash requests quarterly against submitted budget documents, and any issues identified are addressed. The more stringent criteria are fully implemented, and no further corrective actions are needed beyond continuing the current process. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026
Inadequate Support for Federal Reimbursement - Title I - OPI - The Montana Office of Public Instruction partially concurs with this finding. Training and new process documentation were implemented in April 2025 to correct the issue. The previous audit was not completed until October 2024, with the f...
Inadequate Support for Federal Reimbursement - Title I - OPI - The Montana Office of Public Instruction partially concurs with this finding. Training and new process documentation were implemented in April 2025 to correct the issue. The previous audit was not completed until October 2024, with the final audit committee meeting held in December 2024, and the new process was put in place and communicated as quickly as possible. The process is now functioning correctly. The Office has implemented a tracking mechanism to ensure appropriate time reporting. For fiscal year 2027, the Office has added an additional monthly review of each federal budget to confirm that time reported aligns with expected and allocated time for each project. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026
Inadequate Controls Over Maintenance of Effort Calculations - Title I - OPI - The Montana Office of Public Instruction does not concur with this finding. The Office reviews the values provided by the School Finance Division and tests enrollment, average daily attendance, and average number belonging...
Inadequate Controls Over Maintenance of Effort Calculations - Title I - OPI - The Montana Office of Public Instruction does not concur with this finding. The Office reviews the values provided by the School Finance Division and tests enrollment, average daily attendance, and average number belonging to determine whether a local education agency is subject to a percentage reduction under maintenance of effort requirements. When applicable, the Office communicates these results to the local education agency. If a maintenance of effort finding occurs more than once within a five-year period, a reduction is applied to the local education agency’s Title I allocation, and that reduction is entered into the grants management system (eGrants). Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - N/A
Inadequate Access and Privilege Controls - TANF - LIHEAP - CHIP - Medicaid - DPHHS - The Montana Department of Public Health and Human Services completed the development of its accounts matrix for the CHIMES eligibility system in October 2025 and implemented an enhanced process for conducting and do...
Inadequate Access and Privilege Controls - TANF - LIHEAP - CHIP - Medicaid - DPHHS - The Montana Department of Public Health and Human Services completed the development of its accounts matrix for the CHIMES eligibility system in October 2025 and implemented an enhanced process for conducting and documenting access reviews, including verification of user permissions. These improvements have been fully incorporated into routine operations, and the department has implemented all aspects of the audit recommendations. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 10/24/2025
Inadequate Subrecipient Audit Monitoring - TANF - DPHHS - The Montana Department of Public Health and Human Services obtained copies of the Single Audit reports for the two subrecipients identified in the finding and verified the audit outcomes. The department did not document its review of those re...
Inadequate Subrecipient Audit Monitoring - TANF - DPHHS - The Montana Department of Public Health and Human Services obtained copies of the Single Audit reports for the two subrecipients identified in the finding and verified the audit outcomes. The department did not document its review of those reports. The subrecipient relationships in question have since ended. The department will obtain, review, and document its review of subrecipient Single Audit reports, including issuing management decisions on any applicable findings, as required by 2 CFR 200.332(e), and will retain that documentation regardless of whether the subrecipient relationship continues. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 8/31/2026
Inadequate Manual Override Controls - TANF - DPHHS - The Montana Department of Public Health and Human Services implemented a business process in its eligibility system (CHIMES) on May 5, 2026, and revised it on August 25, 2026, to address common override reasons and to document the basis for each o...
Inadequate Manual Override Controls - TANF - DPHHS - The Montana Department of Public Health and Human Services implemented a business process in its eligibility system (CHIMES) on May 5, 2026, and revised it on August 25, 2026, to address common override reasons and to document the basis for each override. Effective August 19, 2026, staff added a targeted question to the monitoring tool regarding manual overrides and issuances to ensure these items are consistently reviewed. The department considers this corrective action implemented and will evaluate its effectiveness during the upcoming monitoring cycle. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 8/25/2026
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