Corrective Action Plans

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2025-031 Adoption Assistance 93.659 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility and child abuse and neglect registry checks, and that this documentation is readily available for audit. We also reco...
2025-031 Adoption Assistance 93.659 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility and child abuse and neglect registry checks, and that this documentation is readily available for audit. We also recommend the Department enhance the renewal letter to include the reaffirmation of the original subsidy agreement date by the participant. Action taken in response to finding: For the finding related to signed adoption subsidy agreements, the Department has already implemented corrective actions to improve its process of maintaining signed adoption subsidy agreements. We built the capacity to upload electronic documents into iFamilyNet in July 2022, and we now ensure that all prospectively signed agreements are uploaded into the child’s iFamilyNet record. In addition, since July 2023, during the Title IV-E eligibility determination process, the eligibility specialist verifies that the signed adoption subsidy agreement has been uploaded. The Department will also explore the auditor’s recommendation to enhance the renewal letter to include the reaffirmation of the original subsidy agreement date by the participant to see if it is technically feasible. Although the Department was unable to produce a copy of a signed subsidy agreement, the Department has controls to oversee that a subsidy agreement was executed prior to legalization of the adoption through a built-in workflow process in our i-FamilyNet system. For the other 39 sample cases, the dates of the signatures by the Department and the pre-adoptive parents recorded in iFamilyNet matched the signature dates on the copies of the original signed agreements. Hence, the Department asserts the dates entered were accurate. We unfortunately could not produce the document to demonstrate that to the auditors. For the finding relating to out-of-state child welfare checks, the Department has already implemented corrective actions to improve its process of documenting requests of out-of-state child welfare checks. In February 2023, the Department integrated the out-of-state child welfare check into the Background Record Check (BRC) section of the foster home licensing process where it can be documented and included as part of the assessment. The Department also added a value to our “contact purpose” drop down menu within the dictation screen in iFamilyNet to capture structured data that an out-of-state child welfare check was made. Name(s) of the contact person(s) responsible for corrective action: Sharon Silvia, Assistant Commissioner of Permanency COMMONWEALTH OF MASSACHUSETTS CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 Planned completion date for corrective action plan: Signed Subsidy Agreements: • July 2022 – capacity to upload electronic documents into iFamilyNet (complete) • July 2023 – eligibility specialist verifies that the signed adoption subsidy agreement has been uploaded (complete) • July 2026 – assess technical feasibility of enhancing the renewal letter Out-of-State Child Welfare Checks: • February 2023 – integrated out-of-state child welfare checks into BRC section and added value to contact purpose drop down (complete)
2025-030 CCDF Cluster 93.575, 93.596 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior year. We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately no...
2025-030 CCDF Cluster 93.575, 93.596 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior year. We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: Over the next year, EEC will revise its written agreements with subrecipients to strengthen internal controls and support program integrity within the Child Care Financial Assistance (CCFA) program. These updates will ensure that agreements clearly reflect state and federal requirements related to CCFA program administration. As part of this effort, EEC will incorporate clearly defined subrecipient key performance indicators (KPIs) and indicators of success, a defined cadence for programmatic coordination meetings, and standardized monitoring checklists to assess adherence to program requirements, including applicable federal requirements. These updates will support clearer expectations for subrecipients administering services and strengthen EEC’s oversight of program implementation. Together, these efforts will promote program integrity, consistency in program administration, and greater accountability across all entities supporting CCFA operations. Name(s) of the contact person(s) responsible for corrective action: Tyreese Nicolas, Deputy Commissioner of Family Access and Engagement Planned completion date for corrective action plan: December 31, 2027
2025-029 CCDF Cluster 93.575, 93.596 Recommendation: We recommend the Department fully implement procedures and internal controls regarding written agreements as part of Program Integrity and Accountability. It should ensure that it fulfills the eight identified requirements including ensuring that ...
2025-029 CCDF Cluster 93.575, 93.596 Recommendation: We recommend the Department fully implement procedures and internal controls regarding written agreements as part of Program Integrity and Accountability. It should ensure that it fulfills the eight identified requirements including ensuring that the program complies with the approved Plan and all Federal requirements, monitoring programs and services, and ensuring that all State and local or non-governmental agencies through which the State administers the program, including agencies and contractors that determine individual eligibility, operate according to the rules established for the program. Action taken in response to finding: The department is putting FFATA reporting procedures in place for all current contracts. Fiscal leadership meets regularly to review and refine federal reporting processes, including FFATA. The fiscal team is also providing FFATA specific training to staff, which will cover the purpose of FFATA reporting, required subrecipient data, and deadlines for collecting and submitting information. Name(s) of the contact person(s) responsible for corrective action: Eric Hansson, CFO Planned completion date for corrective action plan: September 30, 2026
2025-012 Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior year. We recommend the Department review and enhance procedures and controls to ensure that RESEA program requirements are ...
2025-012 Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior year. We recommend the Department review and enhance procedures and controls to ensure that RESEA program requirements are met. We further recommend the Department develop a formal process to review quarterly performance reports for accuracy prior to submission. Action taken in response to finding: In order to resolve this finding, the Department is in the process of creating a new policy and procedure to ensure reports are reviewed prior to submission via the federal reporting system. The policy and procedures will state the process involved in getting report information, review of information, notification to manager, and submittal through the federal reporting system. MDUA has completed a review of policies and procedures. This will be a new effort at formalizing a policy which will go through agency review prior to enactment. MDUA has established an informal policy for staff to follow which speaks to the intent of having a formalized policy. The new policy and procedure will detail the responsibilities of staff who are involved with retrieving the initial information for the report from our UI administrative system, review of information to ensure federal reporting system requirements and comparison to past reports, notification to direct manager that the review was completed, and submittal through the federal reporting system. Name(s) of the contact person(s) responsible for corrective action: John Saulnier, Director of Benefit Performance Planned completion date for corrective action plan: May 1st, 2026
Provided training to staff on HUD EIV requirements and documentation standards. Updated the tenant file checklist to include a mandatory EIV report verification step:  Conducted an internal audit of all tenant files to identify any additional missing or late EIV reports.  Implement a quarterly com...
Provided training to staff on HUD EIV requirements and documentation standards. Updated the tenant file checklist to include a mandatory EIV report verification step:  Conducted an internal audit of all tenant files to identify any additional missing or late EIV reports.  Implement a quarterly compliance review process to ensure ongoing adherence to EIV requirements.
DHS will review existing Medical Assistance and income calculation policies, make any necessary changes, and provide refresher training for staff at all levels of eligibility for various types of Medical Assistance. In addition, reminders about the Medical Assistance Policy will be included in month...
DHS will review existing Medical Assistance and income calculation policies, make any necessary changes, and provide refresher training for staff at all levels of eligibility for various types of Medical Assistance. In addition, reminders about the Medical Assistance Policy will be included in monthly unit meetings. DHS will complete targeted Medical Assistance case reviews, and a review of system (Gateway) designs will be conducted to identify any necessary changes, updates, and additional improvements.
Currently, DCH continues to meet with DHS/DFCS to ensure synchronization of the Georgia Gateway and GAMMIS systems. DCH is proposing additional procedures and policies for DHS/DFCS caseworkers to implement that will terminate members who have been determined ineligible in Gateway but remain active i...
Currently, DCH continues to meet with DHS/DFCS to ensure synchronization of the Georgia Gateway and GAMMIS systems. DCH is proposing additional procedures and policies for DHS/DFCS caseworkers to implement that will terminate members who have been determined ineligible in Gateway but remain active in GAMMIS.
DHS will review existing Medical Assistance and income calculation policies, make any necessary changes, and provide refresher training for staff at all levels of eligibility for various types of Medical Assistance. In addition, reminders about the Medical Assistance Policy will be included in month...
DHS will review existing Medical Assistance and income calculation policies, make any necessary changes, and provide refresher training for staff at all levels of eligibility for various types of Medical Assistance. In addition, reminders about the Medical Assistance Policy will be included in monthly unit meetings. DHS will complete targeted Medical Assistance case reviews, and a review of system (Gateway) designs will be conducted to identify any necessary changes, updates, and additional improvements.
DHS Division of Family and Children Services (DFCS), Temporary Assistance for Needy Families (TANF) program, will review existing TANF and expense statement review policies, and provide refresher training on these policies and applicable forms for staff at all levels of eligibility. TANF management ...
DHS Division of Family and Children Services (DFCS), Temporary Assistance for Needy Families (TANF) program, will review existing TANF and expense statement review policies, and provide refresher training on these policies and applicable forms for staff at all levels of eligibility. TANF management will complete targeted case reviews to ensure that all applicable documentation is included in the file, and peer reviews will be initiated. In addition, a review of the Gateway System will be conducted, and any required form(s) will be updated and included in the case file, if required.
We have documented our procedure for performance reporting so that reports are appropriately reviewed and approved prior to submission.
We have documented our procedure for performance reporting so that reports are appropriately reviewed and approved prior to submission.
GDOL acknowledges that this is a repeat finding from prior years. While the issue has been partially resolved, the Department provides the following response. Claimants who established PUA entitlement with a weekly benefit amount (WBA) greater than the minimum amount, or who were later determined to...
GDOL acknowledges that this is a repeat finding from prior years. While the issue has been partially resolved, the Department provides the following response. Claimants who established PUA entitlement with a weekly benefit amount (WBA) greater than the minimum amount, or who were later determined to be ineligible, did so based on wages self-reported by the claimant and/or wages reported by the employer. Under the CARES Act, claimants were required to submit proof of wages only; however, if proof was not provided, federal guidance permitted payment only at the minimum WBA and did not allow for disqualification of benefits solely due to lack of documentation. For PUA claims initially established at a higher WBA without sufficient proof, the WBA was subsequently reduced to the minimum amount as required. To date, the claimants cited in this finding have not provided the required documentation. The identified PUA claim was adjusted accordingly, and an Overpayment has been established. Disaster Unemployment Assistance (DUA) claims are established under a similar framework as PUA claims, with one key difference: payment requests are currently submitted via paper certification forms. Claimants submit these requests by mail, fax, or email. Because this process is manual, there is an increased risk of misfiling or errors, as occurred in the DUA claim identified. To address these findings and strengthen program integrity, GDOL has implemented and will continue implementing corrective actions and additional safeguards. As system deficiencies were identified, mitigation measures were implemented as quickly as possible to reduce the risk of improper payments. In addition, GDOL’s current UI Information Technology (IT) system was developed in 1982 using mainframe legacy technology. Due to its age and structural limitations, many automated processes and corrective controls cannot be easily implemented. As a result, numerous tasks, including the validation and processing of all PUA and DUA documentation to determine eligibility, must be performed manually by staff. As a long-term measure to strengthen internal controls and improve overall UI program administration, GDOL has partnered with a vendor to implement a modernized UI system. This new system will offer enhanced eligibility determination, improved payment controls, and technological safeguards to support both current and future unemployment programs. Migration to the modernized system is expected in late 2026.
2025-002 Staffing for Adequate Fire and Emergency Response (SAFER) – CFDA No. 97.083 Recommendation: The City should provide training for the grant administrator and/or include an additional review by individual that has been fully trained on the compliance requirements of the grant. The internal co...
2025-002 Staffing for Adequate Fire and Emergency Response (SAFER) – CFDA No. 97.083 Recommendation: The City should provide training for the grant administrator and/or include an additional review by individual that has been fully trained on the compliance requirements of the grant. The internal control process should include a formal way to document the review and approval of Fire Safety salary costs charged to the grant to provide evidence that internal controls are effectively designed and implemented and functioning in a timely manner throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The City has authorized a full-time grants specialist position within the Finance Department to oversee the administration of grants separate from the programming department. The City will strengthen internal controls over grant compliance by implementing formal policies and procedures for allowable costs, documentation, and review. All grant expenditures will be reviewed and approved by Finance prior to submission, with supporting documentation maintained for eligibility determinations. Name(s) of the contact person(s) responsible for corrective action: Rebeca Holden Planned completion date for corrective action plan: 06/30/26 If the Tennessee Comptroller of the Treasury has questions regarding this plan, please call Rebecca Holden at 931-451-0782
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2025-003: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring al...
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2025-003: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring all tenant’s assets are verified at the time of recertification and documentation is maintained in the tenants’ file. Also, the tenant file related to the finding is recertified to determine if the proper tenant rent and HUD assistance payment were accurately calculated for the year ended December 31, 2025. ACTION TAKEN The Project will be continuing to train staff on the HUD Handbook requirements for the tenant files.
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT (CONTINUED) Department of Housing and Urban Development Finding 2025-002: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends...
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT (CONTINUED) Department of Housing and Urban Development Finding 2025-002: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring all tenants’ paperwork is thoroughly reviewed and accurately used in the calculation of the tenant’s required monthly rent and HUD’s tenant assistance payments. ACTION TAKEN The Project billed HUD for the $540 of tenant assistance and will be reimbursing the tenant for the additional rent of $540. The Project will be billing the tenant for the $99 and reimbursing HUD for the additional tenant assistance of $99.
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2025-001: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring al...
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2025-001: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring all current staff are trained on HUD Handbook requirements for tenant files, including the EIV Existing Tenant Search report. ACTION TAKEN The Project will be continuing to train staff on the HUD Handbook requirements for tenant files.
The Town of Spruce Pine will implement written procedures requiring verification of contractor eligibility prior to awarding contracts or subawards funded with federal assistance. Procedures will include verification through SAM.gov, collection of contractor certifications, or inclusion of suspensio...
The Town of Spruce Pine will implement written procedures requiring verification of contractor eligibility prior to awarding contracts or subawards funded with federal assistance. Procedures will include verification through SAM.gov, collection of contractor certifications, or inclusion of suspension and debarment certifications within contracts. Staff involved in procurement and project oversight will receive training on Uniform Guidance requirements, including suspension and debarment compliance.
The Town will implement written procedures requiring the development and maintenance of project‑specific budgets for all federal awards, including FEMA emergency response and recovery projects. Project budgets will be prepared in accordance with approved scopes of work and used to monitor expenditur...
The Town will implement written procedures requiring the development and maintenance of project‑specific budgets for all federal awards, including FEMA emergency response and recovery projects. Project budgets will be prepared in accordance with approved scopes of work and used to monitor expenditures throughout the life of the award. The Town will provide training to applicable staff on federal grant budgeting requirements and designate responsibility for budget preparation and monitoring.
Finding 1213763 (2025-007)
Material Weakness 2025
Corrective Action: Targeted Staff will be completed related on required signatures or date certifying the documentation, and proper documentation which is needed during application and recertification processing. Refresher training on time clocks and associated ABAWD cases. Increased supervisory mon...
Corrective Action: Targeted Staff will be completed related on required signatures or date certifying the documentation, and proper documentation which is needed during application and recertification processing. Refresher training on time clocks and associated ABAWD cases. Increased supervisory monitoring of worker accuracy, with corrective or disciplinary action for repeated errors. Consistent and documented follow-ups by supervisors on all errors identified to confirm corrections are made and understood. The agency's supervisory or lead worker will deliver quarterly refresher sessions covering recurring errors, updated policies, and best practices for both the FNS Intake and Recertification team. Proposed Completion Date: All training will be completed by 2/28/26.
Finding 1213762 (2025-006)
Material Weakness 2025
Corrective Action: Targeted Staff Training were completed related to recertification processes, including proper handling of COVID-extended cases, accessing and working the Pending Recertification Report, proper verification and documentation of vehicles, obtaining long-term medical needs forms when...
Corrective Action: Targeted Staff Training were completed related to recertification processes, including proper handling of COVID-extended cases, accessing and working the Pending Recertification Report, proper verification and documentation of vehicles, obtaining long-term medical needs forms when required, resource verifications, and all required evidence at application and recertification. Additionally, discussions focused on clear standards for requesting information and required case documentation. A monthly Productivity Report (effective January 1, 2026) will be implemented to track individual worker output, identify backlogs early, and ensure timely completion of reviews and recertifications. Increased supervisory monitoring of worker accuracy, with corrective or disciplinary action for repeated errors. Consistent and documented follow-usp by supervisors on all errors identified to confirm corrections are made and understood. State's operational support will deliver quarterly refresher sessions covering recurring errors, updated policies, and best practices for both Family & Children’s and Adult Medicaid programs. Proposed Completion Date: All Training to be completed by 03/28/2026
Those charged with governance agreed with the finding and will work to maintain tenant files in accordance with legislation, regulations, and the terms and conditions of the major federal award program.
Those charged with governance agreed with the finding and will work to maintain tenant files in accordance with legislation, regulations, and the terms and conditions of the major federal award program.
Management acknowledges the auditors’ review of HUD HOME eligibility testing. We believe our current processes generally comply with HUD requirements; however, we recognize the opportunity to strengthen controls. To address the auditors’ comments, we will enhance our eligibility verification procedu...
Management acknowledges the auditors’ review of HUD HOME eligibility testing. We believe our current processes generally comply with HUD requirements; however, we recognize the opportunity to strengthen controls. To address the auditors’ comments, we will enhance our eligibility verification procedures, improve documentation consistency, and provide additional staff training. These corrective actions will help ensure ongoing compliance and accuracy in eligibility determinations. Personnel Responsible for Implementation: Meredith Elguira Position of Responsible Personnel: Community Development Director Expected Date of Implementation: April 30, 2026
The Finance and Administration Department will create an internal policy requiring a copy of the SAM.gov search results for the vendor, including the date of the search, and store the documentation in the appropriate grant file. Further, the policy will require a sign-off process where the vendor pa...
The Finance and Administration Department will create an internal policy requiring a copy of the SAM.gov search results for the vendor, including the date of the search, and store the documentation in the appropriate grant file. Further, the policy will require a sign-off process where the vendor payment cannot be finalized without a "Debarment Check Complete". The Finance and Administration Department will include quality control checks and perform regular internal audits of a sample of vendor files related to grants to check for the presence of the Suspension and Debarment Check. Personnel Responsible for Implementation: Meredith Elguira, Carol Molina, Ralston Turner Position of Responsible Personnel: Interim Community Development Director, Finance and Administration Director, Senior Finance Analyst Expected Date of Implementation: April 30, 2026
Management will conduct a comprehensive review of existing processes and internal controls related to eligibility determination and documentation to ensure alignment with federal requirements. As part of this effort, management will evaluate the timing and sequencing of required signatures to better...
Management will conduct a comprehensive review of existing processes and internal controls related to eligibility determination and documentation to ensure alignment with federal requirements. As part of this effort, management will evaluate the timing and sequencing of required signatures to better reflect operational realities while maintaining compliance.
Personnel Responsible For the Corrective Action: Eric Keith, Director of Finance Anticipated Completion Date September 30, 2026 Corrective Action Plan: The vendor has already updated the financial information page to show the Poverty Scale Base Income and Poverty Scale Increment fields so that a use...
Personnel Responsible For the Corrective Action: Eric Keith, Director of Finance Anticipated Completion Date September 30, 2026 Corrective Action Plan: The vendor has already updated the financial information page to show the Poverty Scale Base Income and Poverty Scale Increment fields so that a user could see how the automated percentage of poverty is calculated. Corrective actions include that within 60 days, the Corporation will determine the root cause of the error, and will implement procedures to have a back-up person manually check the poverty scales within the system after they are updated each year by the data specialist and the data specialist will randomly sample cases opened each day for the first two weeks after the update to verify the calculations and then again quarterly after that. Within 90 days, the Corporation will review cases that were actually over 125%, or other appropriate poverty level limits, and determine if there is any financial impact and report any adjustments.
Finding 2025-001 – Eligibility (Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance) Planned Corrective Action: The Seattle Indian Health Board is implementing enhanced corrective actions to ensure full compliance with Indian Health Service eligibility requiremen...
Finding 2025-001 – Eligibility (Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance) Planned Corrective Action: The Seattle Indian Health Board is implementing enhanced corrective actions to ensure full compliance with Indian Health Service eligibility requirements, specifically related to documentation of Tribal enrollment. While prior corrective actions established foundational training and audit processes, management has identified the need for stronger front-end controls, clearer accountability, and system-based safeguards to prevent recurrence. Seattle Indian Health Board will implement the following actions: 1. Strengthen Front-End Eligibility Controls - Eligibility verification protocols will be updated to require complete Tribal enrollment documentation prior to scheduling non-urgent appointments. - A standardized eligibility checklist will be embedded into intake workflows to ensure all required documentation is identified and collected before services are rendered. 2. System Enhancement and Documentation Tracking - Electronic health record workflows will be enhanced to include required fields and alters for missing eligibility documentation, including Tribal enrollment. - Patients with incomplete eligibility records will be flagged, and services will be limited to allowable scenarios until documentation is obtained. 3. Targeted Training and Competency Validation - All registration and front desk staff will undergo mandatory retraining focused specifically on Tribal enrollment documentation requirements and compliance standards. - Staff competency will be validated through post-training assessments and periodic spot checks. 4. Enhanced Monitoring and Internal Audit - Monthly eligibility audits will be expanded to include a statistically valid sample size and documented review of Tribal enrollment verification. - Audit results will be formally reported to executive leadership, with identified deficiencies tracked through resolution. - Repeat errors or noncompliance will be addressed through corrective coaching and performance management, as appropriate. Management believes these enhanced corrective actions directly address the root cause of the finding by strengthening preventive controls, improving staff competency, and increasing oversight and accountability. Name of Responsible Party: Tempest Dawson, Director of Clinic Operations Anticipated Completion Date: December 31, 2026.
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