Corrective Action Plans

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Statement of Condition: During our testing of compliance with requirements applicable to major federal programs, we noted that the entity did not have formal, consistently applied review and approval controls over key compliance areas. Specifically, evidence of supervisory review and approval was no...
Statement of Condition: During our testing of compliance with requirements applicable to major federal programs, we noted that the entity did not have formal, consistently applied review and approval controls over key compliance areas. Specifically, evidence of supervisory review and approval was not consistently documented for compliance-related transactions. As a result, review procedures appear to be informal, inconsistent, or reliant on individual practices rather than standardized, documented controls. Management Response and Corrective Action Plan: Management agrees with the recommendation and has developed a much more stringent review and approval process. Responsibility of: Chief Finance and Admin Officer, Sherri Emitte Planned Implementation Date of Corrective Action Plan: 2026 Audit
Adeline Montessori School will establish a policy for recording, safeguarding, and maintaining property and equipment purchased with federal funding.
Adeline Montessori School will establish a policy for recording, safeguarding, and maintaining property and equipment purchased with federal funding.
Adeline Montessori School will establish a policy for not entering into a contract with a party that is suspended or debarred and follow this policy for future purchases.
Adeline Montessori School will establish a policy for not entering into a contract with a party that is suspended or debarred and follow this policy for future purchases.
Adeline Montessori School will comply with its procurement policy related to noncompetitive procurement transactions for future purchases.
Adeline Montessori School will comply with its procurement policy related to noncompetitive procurement transactions for future purchases.
Condition: During audit fieldwork, we noted the District’s management has not received a bank reconciliation from the Calumet Township Treasurer for pooled cash and investments. This represents a material weakness in the internal control over financial reporting. Plan: The Superintendent, along with...
Condition: During audit fieldwork, we noted the District’s management has not received a bank reconciliation from the Calumet Township Treasurer for pooled cash and investments. This represents a material weakness in the internal control over financial reporting. Plan: The Superintendent, along with staff, will work with the Calumet Township Treasurer to ensure that monthly bank reconciliations and support documents are performed and received prior to or during audit fieldwork. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Sheryl Colemen – Chief School Board Official Management Response: The CSBO and Superintendent will work with the Calumet Township Treasurer to establish a process to receive monthly bank reconciliation for the pooled cash and investments.
Management agrees with the finding that sliding fee discounts must be applied consistently and in accordance with our approved policy. We are committed to ensuring access to care while maintaining compliance with HRSA program requirements. To strengthen compliance with our sliding fee discount polic...
Management agrees with the finding that sliding fee discounts must be applied consistently and in accordance with our approved policy. We are committed to ensuring access to care while maintaining compliance with HRSA program requirements. To strengthen compliance with our sliding fee discount policy, East Valley Community Health Center has implemented several corrective measures. Re-training for intake and billing staff began in April 2025 and is ongoing as part of our quarterly training cycle. In addition, we are currently reviewing our sliding fee discount policy and procedures to ensure they are clear, consistently applied, and aligned with HRSA guidance and the Health Center Program Compliance Manual. Monthly audits of patient encounters involving sliding fee adjustments began in October 2024 by the billing department and are now a permanent component of our internal compliance process. Audit results are reviewed by our Revenue Cycle Manager and shared with Health Center Administrators and Patient Access Manager, Front Office Leads, and Senior Leadership to ensure accountability and timely corrective action when needed. The CFO is responsible for overseeing these processes and ensuring that all compliance measures are implemented effectively.
2025-003 – Controls Over Disbursements Federal Program Information: Department of Education – Special Education Cluster (IDEA) CFDA – 84.027/84.173 Department of Education – Child Nutrition Cluster CFDA – 10.553/10.555/10.556/10.559/10.579/10.582 Criteria: 2 CFR 200.303 Internal Controls Condition: ...
2025-003 – Controls Over Disbursements Federal Program Information: Department of Education – Special Education Cluster (IDEA) CFDA – 84.027/84.173 Department of Education – Child Nutrition Cluster CFDA – 10.553/10.555/10.556/10.559/10.579/10.582 Criteria: 2 CFR 200.303 Internal Controls Condition: During audit procedures, it was identified that the Supervisory Union did not have internal controls in place to ensure that invoices were properly approved and paid in a timely manner. Cause: Unknown Effect: The Supervisory Union did not always properly approve invoices, could not always locate invoices, and paid invoices beyond the due date. Identification of Questioned Costs: None identified. Context: Between both programs, a total of 43 disbursements were chosen for testing. 11 were adjusting entries. Of the remaining 32, 4 were not paid in a timely manner; 21 were missing either invoices or PO’s or not properly approved. Repeat Finding: This is a repeat finding. Recommendation: It is recommended that the Supervisory Union implement controls to ensure that invoices are managed and paid appropriately. Management Response: Management agrees with the recommendation and will implement controls to ensure that invoices are managed and paid appropriately. Anticipated completion date 7/1/2026
2025-002 – Equipment/Real Property Management Federal Program Information: Department of Education – Special Education Cluster (IDEA) CFDA – 84.027/84.173 Criteria: The following CFR(s) apply to this finding: 2 CFR 200.303 Internal Controls; 2 CFR 200.313(d)(1)(2)(3). Condition: During audit procedu...
2025-002 – Equipment/Real Property Management Federal Program Information: Department of Education – Special Education Cluster (IDEA) CFDA – 84.027/84.173 Criteria: The following CFR(s) apply to this finding: 2 CFR 200.303 Internal Controls; 2 CFR 200.313(d)(1)(2)(3). Condition: During audit procedures, it was identified that the Supervisory Union did not have internal controls in place to ensure that all appropriate equipment and real property management requirements were in place. Cause: Unknown Effect: The Supervisory Union may not be consistently following all appropriate equipment and real property management standards and procedures. There was an instance where the asset purchased equipment did not have a property record and was not recorded in the asset list. Identification of Questioned Costs: None identified. Context: Of the one, and only equipment purchase identified during FY25, there was no property record and it was not recorded on the asset list. Repeat Finding: This is not a repeat finding. Recommendation: It is recommended that the Supervisory Union implements controls to ensure that it follows all appropriate equipment and real property management standards and procedures. We also recommend that the Supervisory Union review its equipment and property policy to ensure that it is updated and complete. Management Response: Management agrees with the recommendation and will implement controls to ensure that we follow all appropriate equipment and real property management standards and procedures. We will also review our equipment and property policy to ensure it is updated and complete. Anticipated completion date 7/1/2026
2025-001 – Procurement/Suspension & Debarment Federal Program Information: Department of Education – Child Nutrition Cluster: CFDA – 10.553/10.555/10.556/10.559/10.579/10.582 Criteria: The following CFR(s) apply to this finding: 2 CFR 200.318 General procurement Standards and 2 CFR 200.214 Suspe...
2025-001 – Procurement/Suspension & Debarment Federal Program Information: Department of Education – Child Nutrition Cluster: CFDA – 10.553/10.555/10.556/10.559/10.579/10.582 Criteria: The following CFR(s) apply to this finding: 2 CFR 200.318 General procurement Standards and 2 CFR 200.214 Suspension and Debarment Condition: During audit procedures, it was identified that the Supervisory Union did not have internal controls in place to ensure that all appropriate procurement standards and procedures were followed. Cause: Unknown Effect: The Supervisory Union may not be consistently following all appropriate procurement standards and procedures. There were instances where the suspension and debarment verification were not performed. Identification of Questioned Costs: None identified. Context: Of the 8 procurement purchases tested, 6 were not verified for suspension or debarment in SAM.gov. Repeat Finding: This is a repeat finding. Recommendation: It is recommended that the Supervisory Union implements controls to ensure that it follows all appropriate procurement standards and procedures. We also recommend that the Supervisory Union review its procurement policy to ensure that it is updated and complete. Management Response: Management agrees with the recommendation and will implement controls to ensure we follow all appropriate procurement standards and procedures. In addition we also will review our procurement policy and ensure it is updated and complete. Anticipated completion date 7/1/2026
Audit Finding Reference: 2025-001 Planned Corrective Action: The Fund is in the process of implementing Agiloft, a comprehensive post-award grants and contracts management system. The system will track and manage post-award grant administration, including budgeting and spending, reporting, task and ...
Audit Finding Reference: 2025-001 Planned Corrective Action: The Fund is in the process of implementing Agiloft, a comprehensive post-award grants and contracts management system. The system will track and manage post-award grant administration, including budgeting and spending, reporting, task and obligation compliance, etc. With this new software the Fund will be better able to monitor and ensure compliance with grant requirements and regulations, particularly the Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards (Uniform Guidance). The Fund is also updating its processes for new award set-up and grant reporting to provide greater clarity around roles/responsibilities, review of award terms, and deliverable tracking and verification. Person(s) Responsible for Corrective Action: The Chief Strategy and Implementation Officer and Chief Financial Officer are coordinating on updating the procedures. The Chief Strategy and Implementation Officer will be responsible for implementing the new contract management software. Anticipated Completion Date: The new software is expected to be implemented by the end of Q4 in fiscal year 2026. The new policy will be updated and implemented by the end of fiscal year 2026.
Finding 2025-001 Program Affected Assistance Listing – 14.881 BangorHousing accepts the recommendations of the audit. Management will reinforce HQS enforcement procedures for timely resolution of inspection findings and termination of payments for units that fail to achieve compliance within the req...
Finding 2025-001 Program Affected Assistance Listing – 14.881 BangorHousing accepts the recommendations of the audit. Management will reinforce HQS enforcement procedures for timely resolution of inspection findings and termination of payments for units that fail to achieve compliance within the required timeframe. Management will ensure staff are property trained and will implement a regular and consistent oversight program to prevent recurrence.
Views of Responsible Officials and Planned Corrective Action Management agreed with the findings and indicated that corrective actions were implemented in January 2026 to ensure employee time is properly tracked and allocated by program, including updated timesheet procedures and enhanced supervisor...
Views of Responsible Officials and Planned Corrective Action Management agreed with the findings and indicated that corrective actions were implemented in January 2026 to ensure employee time is properly tracked and allocated by program, including updated timesheet procedures and enhanced supervisory review.
Views of Responsible Officials and Planned Corrective Action Management agreed with the findings and indicated that corrective actions were implemented in January 2026 to ensure employee time is properly tracked and allocated by program, including updated timesheet procedures and enhanced supervisor...
Views of Responsible Officials and Planned Corrective Action Management agreed with the findings and indicated that corrective actions were implemented in January 2026 to ensure employee time is properly tracked and allocated by program, including updated timesheet procedures and enhanced supervisory review.
Views of Responsible Officials and Planned Corrective Action Management concurred with the finding and indicated that steps will be taken to mitigate the impact of staffing absences and ensure timely submission of all required reports in future periods.
Views of Responsible Officials and Planned Corrective Action Management concurred with the finding and indicated that steps will be taken to mitigate the impact of staffing absences and ensure timely submission of all required reports in future periods.
Recommendation – We realize that with a limited number of office employees, segregation of duties is difficult. However, the District should review the operating procedures of the District to obtain maximum internal control possible under the circumstances.
Recommendation – We realize that with a limited number of office employees, segregation of duties is difficult. However, the District should review the operating procedures of the District to obtain maximum internal control possible under the circumstances.
U.S. Department of Agriculture 2025-008 Weakness in Internal Control Over Compliance of Suspension and Debarment Federal Program: Child Nutrition Cluster — USDA Commodities (15.550), School Breakfast Program (10.553), National School Lunch Program (10.555), Summer Food Service Program for Children (...
U.S. Department of Agriculture 2025-008 Weakness in Internal Control Over Compliance of Suspension and Debarment Federal Program: Child Nutrition Cluster — USDA Commodities (15.550), School Breakfast Program (10.553), National School Lunch Program (10.555), Summer Food Service Program for Children (10.559) Management agrees with the finding and will update the Child Nutrition Procurement Plan and related procedures to ensure suspension and debarment requirements are clearly applied to all covered transactions, including those executed through various procurement methods. Management will also work to design and implement internal controls to ensure suspension and debarment verifications are consistently performed and documented for covered transactions under the Child Nutrition Cluster. Person responsible: Christin Legros, Director of Finance Expected completion date: June 2026
U.S. Department of Agriculture 2025-007 Weakness in Internal Controls Over Compliance of Allowable Costs/Cost Principles of Payroll Disbursements Federal Program: Child Nutrition Cluster — USDA Commodities (15.550), School Breakfast Program (10.553), National School Lunch Program (10.555), Summer Fo...
U.S. Department of Agriculture 2025-007 Weakness in Internal Controls Over Compliance of Allowable Costs/Cost Principles of Payroll Disbursements Federal Program: Child Nutrition Cluster — USDA Commodities (15.550), School Breakfast Program (10.553), National School Lunch Program (10.555), Summer Food Service Program for Children (10.559) Management agrees with the finding and has reviewed the payroll items identified during the audit and has taken corrective action to address schedule discrepancies and unsupported payroll entries. Management has conducted a review of employee schedules within the timekeeping system to ensure alignment with payroll records and has corrected errors identified. Management plans to continue performing periodic reviews of payroll data to identify potential discrepancies and to take corrective action as needed. Management will also evaluate identified payroll discrepancies on a case‑by‑case basis to determine whether recovery or adjustment is appropriate. Person responsible: Christin Legros, Director of Finance Expected completion date: June 2026
U.S. Department of Education 2025-006 Weakness in Internal Control Over Compliance of Suspension and Debarment Federal Program: Special Education Cluster (IDEA); Special Education – Grants to States (IDEA, Part B) Assistance Listing No. 84.027, Special Education – Preschool Grants (IDEA, Part B – Pr...
U.S. Department of Education 2025-006 Weakness in Internal Control Over Compliance of Suspension and Debarment Federal Program: Special Education Cluster (IDEA); Special Education – Grants to States (IDEA, Part B) Assistance Listing No. 84.027, Special Education – Preschool Grants (IDEA, Part B – Preschool) Assistance Listing No. 84.173 Management agrees with the finding and will work on designing and implementing internal controls to ensure suspension and debarment verifications are performed and documented for covered transactions under the Special Education Cluster. Person responsible: Christin Legros, Director of Finance Expected completion date: June 2026
Management’s Response/Corrective Action Plan: The Town was unaware of the suspension and debarment requirements under Uniform Guidance §200.214. Upon notification of this finding, the Town has implemented corrective measures to ensure compliance. Effective immediately, the Town will verify all vendo...
Management’s Response/Corrective Action Plan: The Town was unaware of the suspension and debarment requirements under Uniform Guidance §200.214. Upon notification of this finding, the Town has implemented corrective measures to ensure compliance. Effective immediately, the Town will verify all vendors before contract execution by searching SAM.gov to confirm they are not suspended or debarred. Additionally, the Town will require vendors to provide written certification of their suspension and debarment status. Documentation of both the SAM.gov verification and vendor certification will remain with the applicable grant records. These procedures will be incorporated into the Town’s standard procurement practices and will apply to all federally funded projects, including a $1.1 million Congressionally Directed Spending (CDS) award for which the Town awaits receipt.
Finding 2025-001 Fiscal year in which the finding occurred: 2025 Pass-Through Entity, if pass-through or Federal Grantor Agency, if direct: U.S. Department of Labor Contact person responsible for the corrective action: Michael Brey Description of Audit Finding: An effective internal control system w...
Finding 2025-001 Fiscal year in which the finding occurred: 2025 Pass-Through Entity, if pass-through or Federal Grantor Agency, if direct: U.S. Department of Labor Contact person responsible for the corrective action: Michael Brey Description of Audit Finding: An effective internal control system was not designed or implemented at the Organization related to payroll and incentives/subscriptions to ensure compliance with requirements related to the grant agreements and Allowable Costs/Cost Principles compliance requirements. Corrective Action to be Taken: Beginning in April 2026, the organization has changed the process to record payroll to be charged to the grant. A spreadsheet has been created to track each payroll register and the amounts paid to each employee assigned to the grant. This data will be tracked throughout the year and checked against the payroll amount allowed per the grant budget. If any adjustments are required, that will happen in June and December. The payroll spreadsheet will be reviewed by a second employee to validate the spreadsheet is correct. Beginning in February 2026 the organization has corrected the subscription pricing to $1,500 per eligible shop. Additionally, the organization identified that certain shop incentives were being overcharged to the grant due to sales tax being added to the tool kit. The organization has adjusted the composition on the tool kit to reduce the amount including sales tax to be under the $8,500 allowable limit. Any excess incentive awarded in 2026 will not be submitted to the DOL for reimbursement from the grant. The tracking file for shop incentive awards is reviewed by the Controller. Correcting adjustments will be made to the grantor financial reports in 2026 to correct the overcharged payroll costs and incentives/subscription costs identified in 2025 and to properly reflect the cumulative grant expenditures in accordance with Allowable Costs/Cost Principles compliance requirements. Grantor financial reports will be reviewed by a second employee. Anticipated completion date: New process in place effective 4/1/26.
Agency personnel will ensure all documentation and support is maintained.
Agency personnel will ensure all documentation and support is maintained.
Agency personnel will ensure costs that are charged to federal awards were incurred during the applicable period of performance and recorded in the correct period.
Agency personnel will ensure costs that are charged to federal awards were incurred during the applicable period of performance and recorded in the correct period.
Agency personnel will ensure they are minimizing the time between the transfer of funds from the federal awarding agency and the disbursement of those funds.
Agency personnel will ensure they are minimizing the time between the transfer of funds from the federal awarding agency and the disbursement of those funds.
Procurement, Suspension, and Debarment Auditor Description of Criteria, Condition, and Effect: Under the requirements of 2 CFR Part 180 covered transactions for procurement and nonprocurement contracts that are expected to equal or exceed $25,000, the grantee must verify that the party being awarded...
Procurement, Suspension, and Debarment Auditor Description of Criteria, Condition, and Effect: Under the requirements of 2 CFR Part 180 covered transactions for procurement and nonprocurement contracts that are expected to equal or exceed $25,000, the grantee must verify that the party being awarded procurement and nonprocurement contract is not suspended, debarred, or otherwise excluded by checking the list of excluded parties, obtaining certification from the vendor or subrecipient, or including a clause or condition to the covered transaction with that entity. For two out of two vendors selected for testing, the YMCA was unable to provide evidence that the vendors were not suspended, debarred, or otherwise excluded at the time they were engaged to provide goods or services. As a result of this condition, the YMCA was exposed to an increased risk that disbursements of federal awards could be made to vendors suspended or debarred by the federal government. Auditor Recommendation: We recommend that the YMCA review its written policies and procedures over federal awards with employees responsible for grant compliance to ensure that they are being followed consistently. Corrective Action: YMCA relied upon outside legal counsel for guidance in the procurement process. In the future, YMCA will perform this procedure or ensure that legal counsel performs this procedure. Responsible Person: Phil Platz, CFO Anticipated Completion Date: 6/12/2026
Procurement, Suspension, and Debarment Auditor Description of Criteria, Condition, and Effect: Recipients of federal awards are required to ensure that federal procurement standards are followed for any purchases over the federal micropurchase threshold. 2 CFR 200.320 requires that these purchases m...
Procurement, Suspension, and Debarment Auditor Description of Criteria, Condition, and Effect: Recipients of federal awards are required to ensure that federal procurement standards are followed for any purchases over the federal micropurchase threshold. 2 CFR 200.320 requires that these purchases must adhere to one of the allowable procurement methods (sealed bids, competitive proposals, noncompetitive procurement) and maintain documentation of this procurement decision In addition, the Uniform Guidance requires a non-federal entity that has expended federal awards for a grant awarded on or after December 26, 2014 to have written policies pertaining to Procurement (including bidding and a conflict of interest policy) (§200.318). For one of the two vendors tested, the YMCA was unable to provide documentation to support that competitive bidding was performed in accordance with the YMCA's policies and procedures. Although the YMCA has processes in place to cover these areas, we noted during review of procurement policies, that management has two procurement policies, one for general competitive bids and one for federal funds. We noted that while the federal funds procurements thresholds are in line to what is required by 2 CFR 200.318, the policy was not being followed consistently. As a result of this condition, one vendor was paid with federal funding for which appropriate procurement records were not maintained in accordance with federal procurement standards. The YMCA did not fully comply with the Uniform Guidance applicable to the above noted grant. Auditor Recommendation: We recommend that the YMCA review its written policies and procedures over federal awards with employees responsible for grant compliance to ensure that they are being followed consistently. Corrective Action: Although we performed the proper procedures, the passage of time resulted in a misplacing of the supporting documentation. We relied upon legal counsel to retain the documentation. This was a unique and one-time award. In the future, we will take responsibility for the retention of the supporting documentation, Responsible Person: Phil Platz, CFO Anticipated Completion Date: 6/12/2026
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