Corrective Action Plans

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Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate ...
Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate documentation to verify primary residence status as part of the CDBG/HOME loan reconciliation workbook process.  Implementing periodic monitoring procedures for loan recipients.  Maintaining documentation in loan files to support compliance throughout the affordability period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with the finding and has implemented loan file monitoring procedures to verify occupancy compliance. Name of the contact person responsible for corrective action: Melanie Marquez Planned completion date for corrective action plan: 6/30/2026
Finding 1221502 (2025-003)
Material Weakness 2025
Hips
DC
Views of Responsible Officials: HIPS experienced significant delays in receiving approved budgets, Notice of grant awards (NOGAs) and Purchase Orders (POs) from the grantors. HIPS cannot submit reports without these documents. For these reasons, HIPS could not meet the requirement "timely submission...
Views of Responsible Officials: HIPS experienced significant delays in receiving approved budgets, Notice of grant awards (NOGAs) and Purchase Orders (POs) from the grantors. HIPS cannot submit reports without these documents. For these reasons, HIPS could not meet the requirement "timely submission of required reports". We hope that in the future, HIPS will receive the pre-requisite documentation on time. In addition, the grantors' systems are set in a chronological order and therefore even in instances where HIPS is ready to submit reports HIPS can only submit one month and wait for that month's report to be approved before HIPS can submit the next month. This system,albeit important in grant management, limits HIPS ability to fulfil "timely submission of required reports" requirements. HIPS will improve documentation on this issue.
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and...
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and managing files. All forms are now saved in tenant files, and not on individual laptops as they were in the past. The supervisor has also implemented schedules and tracking systems for monthly voucher submissions, annual recertifications, quarterly income checks and other processes in the occupancy workflow. In addition, the supervisor and the lead staff for housing compliance perform regular checks on tenant application paperwork and random checks on tenant files to ensure accuracy and completeness and correct any mistakes. Ongoing staff training, support and mentoring continues.
Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027) Recommendation: We recommend that the Organization establishes a documented review process for eligibility determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. However, it should...
Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027) Recommendation: We recommend that the Organization establishes a documented review process for eligibility determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. However, it should be noted that we are in compliance with the requirements of Ramsey County, Minnesota (the administrator of the ARPA program) as to documentation, reporting and other requirements. Documentation of review of income eligibility is not required by Ramsey County. Action taken in response to finding: We will immediately implement a sign off procedure by staff when they review income eligibility. Name of the contact person responsible for corrective action: Chris Schmidt Planned completion date for corrective action plan: Immediate
Corrective Action Plan (CAP): The College has reviewed the student identified in this finding and confirmed that the student had been placed on financial aid suspension during a previous term due to exceeding the 150% maximum timeframe for program completion, but the suspension status was not reflec...
Corrective Action Plan (CAP): The College has reviewed the student identified in this finding and confirmed that the student had been placed on financial aid suspension during a previous term due to exceeding the 150% maximum timeframe for program completion, but the suspension status was not reflected when the student's enrollment was subsequently evaluated, resulting in the student receiving Title IV aid for which they were not eligible during the period under audit. The College has identified that this occurred in connection with how the student's enrollment was recorded across programs within Anthology, the College's student information system, and is continuing to investigate the precise cause of the system behavior that allowed the student's Satisfacto1y Academic Progress (SAP)/150% status to not carry forward or recalculate appropriately. The aid improperly disbursed to this student has been identified, and repayment has been completed.
ELIGIBILITY VERIFICATIONS – GRANTS TO STATES FOR MEDICAID PROGRAM Recommendation: It is recommended that the County increase review over casefiles and ensure verifications are sent out when necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Ac...
ELIGIBILITY VERIFICATIONS – GRANTS TO STATES FOR MEDICAID PROGRAM Recommendation: It is recommended that the County increase review over casefiles and ensure verifications are sent out when necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will remind staff to perform reviews and to ensure that verifications are sent out when necessary. Name of the contact person responsible for corrective action plan: Kayla Matter, HHS Deputy Director Planned completion date for corrective action plan: December 31, 2026
Finding 1221287 (2025-004)
Material Weakness 2025
Eligibility Determination Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesot...
Eligibility Determination Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5MAP and 2505MN5ADM Compliance Requirement Affected: Eligibility Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: It is recommended the County implement procedures to ensure the citizenship, asset, and income verification documentation in the casefiles be retained and that it matches the METS eligibility system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will review procedures and show staff proper documentation and entry into METS and staff will be reminded to perform reviews. Name of the contact person responsible for corrective action plan: Loni Swenson, Finance Director Planned completion date for corrective action plan: December 31, 2026
We have implemented a plan for proper training to make sure everyone is aware of HUD rules regarding family eligibility. We will complete a quarterly audit of randomly selected files to ensure we are adhering to HUD rules. We will ensure staff monitors eligibility for each resident within the requir...
We have implemented a plan for proper training to make sure everyone is aware of HUD rules regarding family eligibility. We will complete a quarterly audit of randomly selected files to ensure we are adhering to HUD rules. We will ensure staff monitors eligibility for each resident within the required time frame.
Assistance Listing 14.239 – HOME Investment Partnership Program Material Weakness in Internal Control over Compliance; Material Noncompliance – Eligibility Background of Occurrence: For the year under audit, not all tenant income re-certifications were found in paper or digital form in the company f...
Assistance Listing 14.239 – HOME Investment Partnership Program Material Weakness in Internal Control over Compliance; Material Noncompliance – Eligibility Background of Occurrence: For the year under audit, not all tenant income re-certifications were found in paper or digital form in the company files after the termination of the former property manager in February, 2026. Planned Corrective Action: To address this issue prospectively, WCCAC has implemented an internal system to ensure re-certifications are completed timely, with three levels of accountability as outlined in the new Homes Program Internal Control Compliance Memo (see attached) Under Paragraph “Control Activities” it outlines new corrective action procedures to ensure compliance. Anticipated Completion Date: April, 2026 – This corrective action has been incorporated immediately into our internal processes. Name and Title of Contact Person Responsible for Corrective Action: Timothy Fisher, Chief Executive Officer
Community Mental Health Services of Livingston County Single Audit Report: Corrective Action Plan Year ended September 30, 2025 Finding 2025-001- Suspension and Debarment Requirement: As required by 2 CFR 200.214, Non-Federal entities are subject to the non-procurement debarment and suspension regul...
Community Mental Health Services of Livingston County Single Audit Report: Corrective Action Plan Year ended September 30, 2025 Finding 2025-001- Suspension and Debarment Requirement: As required by 2 CFR 200.214, Non-Federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. Condition: The vendor used for this grant was not checked for suspension and debarment prior to execution of the contract. Also, the contract did not include certification that vendor was not suspended or debarred. Questioned Cost: None. Recommendation: We recommend that the CMHSP update contract language to include certification that vendor is not suspended or debarred. Corrective Action Plan LCCMHA will address the concern raised by RPC and agrees with the above recommendation. The Accounting Manager and Associate Director of Finance and Contracts will work with the Contract Manager to modify existing contract language to include certification that vendors are not suspended or debarred. This change will be implemented for fiscal year 2027 commencing 10/01/26. Responsible Party: Jim Kubus, Accounting Manager Anticipated completion date: September 30, 2026
Finding 2025-001: Eligibility Recommendation: We recommend that management establish and implement formal policies and procedures for the administration of the FSEOG program, including clear guidance on the minimum and maximum award limits in accordance with federal regulations. Management should al...
Finding 2025-001: Eligibility Recommendation: We recommend that management establish and implement formal policies and procedures for the administration of the FSEOG program, including clear guidance on the minimum and maximum award limits in accordance with federal regulations. Management should also provide adequate training to Financial Aid Office personnel on applicable federal requirements, perform supervisory reviews of award calculations prior to disbursement, and conduct periodic monitoring to ensure ongoing compliance with established limits. Response: The College acknowledges the findings resulting from the initial year of the Federal Supplemental Educational Opportunity Grant (FSEOG) program's implementation. The College recognizes that the finding resulted from deficiencies in newly implemented award procedures during the first year of the FSEOG program. In light of this, we wish to provide context regarding the situation and the corrective actions undertaken to address the issue. The seven students identified in this finding were awarded FSEOG funds that reflected their significant financial need and the institution's commitment to enabling students to cover both direct and indirect enrollment costs. An internal review conducted by the Financial Aid Office revealed that these awards inadvertently exceeded the $4,000 annual maximum established by program regulations. Following this internal review, prompt corrective measures were enacted, culminating in the issuance of a formal memorandum to the Comptroller in October of FY26. This memorandum directed adjustments to the affected students’ FSEOG awards to ensure compliance with the prescribed annual maximum. This internal monitoring process underscores the College’s proactive commitment to program integrity and fiscal accountability. Furthermore, the unexpended funds were returned to the U.S. Department of Education during FY26. The College remains dedicated to the proper administration of the FSEOG program and has reinforced its internal review procedures. This includes conducting more frequent audits of award ceilings during active disbursement periods to prevent similar errors in future award years. To address the finding, the College will implement the following actions: 1. Establishment of Formal Policy and Standard Operating Procedures (SOPs): Within 30 days, the College will adopt and implement a dedicated section within the Financial Aid Policy and Procedures Manual specifically for the FSEOG program. This document will delineate federal award limitations, selection criteria based on exceptional financial need groupings, and compliance parameters in accordance with 34 CFR 676.20. 2. Staff Training and Competency Review: Prior to the next award cycle, the College will conduct a mandatory training workshop for all counselors and processing staff within the Financial Aid Office. This training will emphasize the identification of the FSEOG-eligible student population, the applicable selection criteria, and the importance of cross-referencing final award packages. 3. Monitoring and Long-Term Quality Control: The College will implement a mandatory two-tiered verification process. Prior to any FSEOG batch disbursement being sent to the Office of the Comptroller for final payment execution, a senior financial aid officer or director must review and authorize a compliance checklist. This checklist will confirm that there are no boundary violations, and any batch disbursement package containing an amount below $100 or exceeding $4,000 per academic year will be flagged for review. Quarterly compliance reviews will be documented and retained as part of the College's internal control records to verify continued compliance with FSEOG award requirements and to provide supporting documentation for future audits. Primary Responsible Office: Director, Financial Aid Office Oversight Office: Vice President for Enrollment Management and Student Services Overall CAP Completion Target: Addressed in Dec 2026
Finding No. 2025-001: Missing Deadlines for Recertifications and Inspections (Significant Deficiency) Corrective Action Plan: Our goal is to address the underlying cause of the delayed recertifications and inspections identified in Finding 2025-001. Regarding the recertifications, my analysis of the...
Finding No. 2025-001: Missing Deadlines for Recertifications and Inspections (Significant Deficiency) Corrective Action Plan: Our goal is to address the underlying cause of the delayed recertifications and inspections identified in Finding 2025-001. Regarding the recertifications, my analysis of the delays indicates that our Housing Voucher team remains understaffed. We have a five-person Housing Voucher Team with well over 900 vouchers to administer across a variety of different programs, including HCV, PBV, Mainstream, VASH, Foster Youth, Port-In1, etc. Additionally, we have 80 public housing units and are administering an additional 80 project-based tenant-protection vouchers in partnership with Montgomery Housing Partnership (MHP) for a senior-housing rehab project (Bethany House) begun this year (2026). In short, we need to expand our housing voucher team, especially since only one member of the team, Eve Garcia Jiminez, specializes in port-ins. Additionally, while Ms. Garcia Jiminez and Ms. Rebecca Niaba, the Housing-Voucher Team Manager, both have considerable experience with HUD programs, the remaining three team members – who handle resident casework, recertifications, waitlist management, inspections, etc. – are relatively junior, all with less than five years of experience. Since RHE’s leadership turnover in late August 2025, we have attempted to supplement the Housing Voucher Team with interns from our YouthBuild program. While this has helped somewhat lessen the burden, the RHE Management Team has determined that we need at least one additional mid-career Housing-Voucher Team member (minimum 5+ years of experience managing HUD voucher programs). We are considering a variety of options, including recruiting a Deputy for the Housing Voucher Team or promoting one of our Team Members to Deputy Director and backfilling a mid-career position. We have also begun discussions with WorkSource Montgomery and AmeriCorps Maryland to potentially supplement the initial costs of onboarding new Voucher Team members. For the inspections finding, we have been having discussions since the RHE leadership turnover about the performance of our current vendor, Gilson Housing Partners. They have been increasingly unreliable since we selected them as our inspections vendor in February 2025. Just in the last few weeks, we havedetermined that we need to terminate the vendor, particularly after we received a video of an inspection where the Gilson representative spent approximately 80 seconds in the unit, never left the entryway, and only asked the resident a few questions before leaving. We have already received one proposal from Archer-Greenwood Companies and expect 2-3 more proposals in the next few weeks, at which point we will submit a notice of termination to Gilson. Responsible Person: James Hedrick, Interim Executive Director Anticipated Completion Date: Recertifications & Voucher Team Hiring - AmeriCorps Maryland – Applications due July 1, 2026. Participants’ terms begin August/September 2026 and last for one year – extendable as full-time employee after the AmeriCorps subsidy. - Housing-Voucher Team Deputy Director/Mid-Career Port-In Specialist – The position requires a particular set of skills and experience in a specialized area. Recruitment and advertisement are expected to take some time. Advertising for the position will begin late Summer 2026, hiring expected before year-end 2026. Inspections Vendor Replacement - Have already received proposals from one potential inspection replacement firm: Archer- Greenwood. We have reached out to additional vendors and expect proposals within the next few weeks. We will send a letter of termination and fully transition to the new vendor by the end of FY2026 (September 30, 2026).
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
Documented Policies and Procedures related to Suspension and Debarment Recommendation: ICHCA should implement formal written policies in compliance with suspension and debarment requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action plan...
Documented Policies and Procedures related to Suspension and Debarment Recommendation: ICHCA should implement formal written policies in compliance with suspension and debarment requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: ICHCA staff were provided a refresher on suspension and debarment documentation requirements, and policies and procedures were updated to emphasis the need to retain documentation of exclusion and debarment inquiries. Personnel have been filing documentation with contracts as of April 2026. Name(s) of the contact person(s) responsible for corrective action: Kyle Rooks, CEO Planned completion date for corrective action plan: April 2026
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to incorrect participant meal coding and reimbursement classifications. Management has implemented the following corrective actions: 2...
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to incorrect participant meal coding and reimbursement classifications. Management has implemented the following corrective actions: 2 4 Provide refresher training to all staff responsible for determining and entering participant eligibility classifications. Develop written procedures outlining eligibility determination requirements and reimbursement coding standards. Conduct periodic internal audits of participant eligibility classifications to identify and correct errors timely. Maintain documentation of training attendance and ongoing monitoring activities. Responsible Party Sonja Williams and Site Coordinators Expected Completion Date September 30, 2026
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to missing participant eligibility documentation maintained by operating sites. Management has implemented the following corrective ac...
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to missing participant eligibility documentation maintained by operating sites. Management has implemented the following corrective actions: 1. Establish standardized procedures requiring all operating sites to submit enrollment forms and Income Eligibility Forms prior to reimbursement claims being submitted. 2. Develop a monitoring checklist to verify that all required participant documentation is collected, complete, and retained. 3. Require monthly compliance reviews of participant files for each operating site. 4. Provide additional training to site administrators regarding CACFP eligibility documentation and retention requirements. Responsible Party Jeff Reynolds and Sonja Williams Expected Completion Date September 30, 2026
The Economic Security Administration (ESA) concurs with this finding. ESA will review its current case review procedures to ensure that prioritization of assignments aligns with regulatory timeliness requirements. Based on the results of this review, ESA will update its procedures as needed.
The Economic Security Administration (ESA) concurs with this finding. ESA will review its current case review procedures to ensure that prioritization of assignments aligns with regulatory timeliness requirements. Based on the results of this review, ESA will update its procedures as needed.
The Child and Family Services Agency (CFSA) concurs with the finding. The June 2025 implementation of STAAND, CFSA’s new system, included safeguards to mitigate the generation of claims for federal reimbursement for payments made to any provider for which there is a critical licensure issue.
The Child and Family Services Agency (CFSA) concurs with the finding. The June 2025 implementation of STAAND, CFSA’s new system, included safeguards to mitigate the generation of claims for federal reimbursement for payments made to any provider for which there is a critical licensure issue.
The Division of Program Operations (DPO) of DHS acknowledges and agrees with the audit findings and related observations. After reviewing the issues identified, DPO is implementing targeted corrective measures to strengthen internal controls and ensure full compliance with eligibility documentation ...
The Division of Program Operations (DPO) of DHS acknowledges and agrees with the audit findings and related observations. After reviewing the issues identified, DPO is implementing targeted corrective measures to strengthen internal controls and ensure full compliance with eligibility documentation requirements. DPO remains committed to executing these corrective actions promptly and maintaining strong internal controls that support accurate eligibility determinations, program integrity, and adherence to federal and District requirements. DPO, in collaboration with DCAS and the Policy Unit, has initiated efforts to align the required language with the DCAS electronic platform and the caseworker portal’s IEG scripts.
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