Corrective Action Plans

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The District bookkeeper, along with food service staff, will thoroughly review applications in for completeness.
The District bookkeeper, along with food service staff, will thoroughly review applications in for completeness.
The local agency’s internal second party worksheet has been updated according to policy and includes a weighted score for monitoring error trends and patterns for individual staff and the unit. Supervisors complete second party reviews monthly for all staff, hold individual worker conferences monthl...
The local agency’s internal second party worksheet has been updated according to policy and includes a weighted score for monitoring error trends and patterns for individual staff and the unit. Supervisors complete second party reviews monthly for all staff, hold individual worker conferences monthly to review discrepancies discovered providing instruction as needed. NCFAST Learning Gateway will be utilized if a specified training is available. Targeted training/instruction is provided during monthly team meetings to review errors and provide guidance and instruction to staff for policy and NC FAST functionality updates. Restructure of the units/staff responsible for administration of the Food and Nutrition Services program will be implemented to separate the required functions for case management. The goal will be to streamline workflow processes with managing all three functions (application, processing, case recertification), promote more efficient time management with respect to interviewing and case processing and increase productivity while decreasing errors.
Utilizing the State provided DHB-7078 - 2nd Party Review Worksheet, which separated evaluation for applications and recertifications, to complete targeted case reviews on error prone areas. These areas include the areas identified during the audit and include sections surrounding income, resources a...
Utilizing the State provided DHB-7078 - 2nd Party Review Worksheet, which separated evaluation for applications and recertifications, to complete targeted case reviews on error prone areas. These areas include the areas identified during the audit and include sections surrounding income, resources and documentation. Supervisors complete second party reviews monthly for all staff and continue to hold individual worker conferences monthly to review discrepancies discovered providing instruction as needed. NCFAST Learning Gateway will be utilized if a specified training is available. Targeted training/instruction is provided during monthly team meetings to review errors and provide guidance and instruction to staff for policy and NC FAST functionality updates.
Controls have been strengthened to ensure that the front desk accurately enters applicants’ income and family size into the ECW system when determining eligibility for the sliding fee schedule. A member of the Finance Department is reviewing all sliding fee applications. These policies and procedure...
Controls have been strengthened to ensure that the front desk accurately enters applicants’ income and family size into the ECW system when determining eligibility for the sliding fee schedule. A member of the Finance Department is reviewing all sliding fee applications. These policies and procedures have been implemented to improve accuracy and compliance. Policy 01-03-029 – Sliding Fee Audit Policy was implemented on June 1, 2025. This policy includes the following: The Compliance Officer conducts a monthly audit, with audit results submitted to the Risk Manager on a quarterly basis. The Front Desk Trainer provides additional training to any employee who receives a failing score on an audit. This training is documented and signed off by the employee, the Front Desk Trainer, and the employee’s supervisor. Disciplinary actions are as follows: 1. First occurrence – One-on-one training 2. Second occurrence – Verbal warning and additional training 3. Third occurrence – Written warning 4. Fourth occurrence – Up to and including termination Mandatory training was conducted on January 14th and 15th and included all site managers, operations managers, the CFO, and the COO. Additional Controls Implemented: Effective July 1, 2025, all sliding fee applications are reviewed by a member of the Finance Department. The front desk is required to make any corrections or changes identified during the finance review. In addition, a task force has been formed to ensure appropriate follow-up is completed and to identify new opportunities to improve accuracy and compliance for all sliding fee patients. The front desk has also been provided with an Excel-based tool to assist with accurately entering patient income.
The College’s Vice President for Academic Affairs and Dean of the College concurred with the finding identified. The College has revised its policies and procedures as follows: Historically, Student Affairs coded only those students who took a Leave of Absence during the semester (“L”) or withdrew d...
The College’s Vice President for Academic Affairs and Dean of the College concurred with the finding identified. The College has revised its policies and procedures as follows: Historically, Student Affairs coded only those students who took a Leave of Absence during the semester (“L”) or withdrew during the semester (“W”). Student Affairs has created a new code (“N”) to track students who inform the college of their intent to withdraw at the end of a given semester. At the end of each semester, Student Affairs provides the Registrar’s Office with a report of all students who informed the college of their intent to unenroll (“L”, “W”, and “N”). Using the report, the Registrar’s Office confirms that all students have been accurately exited with the appropriate exit date and exit reason prior to submitting the final “end of term” report to the National Student Clearinghouse. This new process was implemented beginning in the Fall 2025 semester. The corrective actions will be implemented by Dr. Kristen M. Amick, Registrar. Dr. Amick’s email address is: amickkm@westminster.edu.
Americorps Seniors Senior Companion Program – Assistance Listing No. 94.016 Recommendation: We recommend that additional review procedures are put in place to ensure the volunteer type is accurate based on their income review. Explanation of disagreement with audit finding: There is no disagreement ...
Americorps Seniors Senior Companion Program – Assistance Listing No. 94.016 Recommendation: We recommend that additional review procedures are put in place to ensure the volunteer type is accurate based on their income review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Program leadership will review and update existing policies and procedure manuals to ensure provide clear and accurate steps to adhere to funding guidance. The supporting technology will be updated in a manner that will require program coordinators/managers to actively complete a required field to verify current income eligibility. In addition, the program will develop and implement an active review process to monitor and support compliance and accurate record keeping. Name(s) of the contact person(s) responsible for corrective action: Drew Erickson Planned completion date for corrective action plan: 02/28/2026
Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: We recommend the College implement a review process that compares enrolled credits to Pell awards to ensure all students receive the correct Pell Grant amounts. Explanation of disagreement with audit finding: There is no d...
Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: We recommend the College implement a review process that compares enrolled credits to Pell awards to ensure all students receive the correct Pell Grant amounts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: There was one student in Fall 2024 who was under-awarded Pell Grant funds due to an error related to the student’s withdrawal status and the number of credits attempted. The Pell award was manually processed incorrectly based on this enrollment change. Beginning in Spring 2025, the Financial Aid team implemented a new process requiring a formal review of enrollment intensity for all students prior to determining and disbursing Pell Grant funds. This ensures that Pell awards are calculated and adjusted accurately. Additionally, the team now utilizes enrollment and Pell related reports to help identify potential changes in student enrollment and support timely, accurate award reviews. Name(s) of the contact person(s) responsible for corrective action: Dr. Carla Dirkshneider, VP of Enrollment and Retention Planned completion date for corrective action plan: Corrective action was implemented January, 2025.
Student Financial Aid Cluster – Assistance Listing No. Various Recommendation: We recommend the College review the R2T4 requirements and implement procedures to ensure that calculations use the correct number of break days and are completed accurately and within the required timeframes. Explanation ...
Student Financial Aid Cluster – Assistance Listing No. Various Recommendation: We recommend the College review the R2T4 requirements and implement procedures to ensure that calculations use the correct number of break days and are completed accurately and within the required timeframes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the review period, two students did not receive their Return to Title IV (R2T4) calculations within the required 45-day timeframe. The delay occurred because the Financial Aid Office did not receive the corresponding change of registration forms from the Registrar’s Office, which is necessary to initiate the R2T4 process. To prevent recurrence, the Financial Aid Office has implemented the following corrective actions: 1. Monitoring Reports: The team now runs a student status change report to independently identify potential R2T4 cases, even if documentation has not yet been forwarded. 2. Improved Communication Workflow: Financial Aid has been added to the Registrar’s change of registration email distribution list to ensure timely notification of withdrawals, drops, and status changes. These measures strengthen internal controls, improve cross departmental communication, and ensure that all future R2T4 calculations are completed within federal timelines. Name(s) of the contact person(s) responsible for corrective action: Dr. Carla Dirkshneider, VP of Enrollment and Retention Planned completion date for corrective action plan: Corrective action was implemented in June 2025.
1. To Provide Mandatory training to accounting personnel on certain accounting principles regarding
1. To Provide Mandatory training to accounting personnel on certain accounting principles regarding
HUD Multifamily Housing. This includes taking accounting continuing education classes in accounting
HUD Multifamily Housing. This includes taking accounting continuing education classes in accounting
for HUD Projects. Create an Internal Auditing function. Management provide a structure and process
for HUD Projects. Create an Internal Auditing function. Management provide a structure and process
to review and monitor the processing of monthly financial statements and transactions. Management
to review and monitor the processing of monthly financial statements and transactions. Management
must also review and monitor the processing of monthly bank reconciliations. By providing these
must also review and monitor the processing of monthly bank reconciliations. By providing these
processes it will reduce the risk of material misstatements and increase the likelihood that financial
processes it will reduce the risk of material misstatements and increase the likelihood that financial
statements will be produced at a reasonable period after year end.
statements will be produced at a reasonable period after year end.
2. Management utilizing the Internal Audit Function should revise its internal control system as follows:
2. Management utilizing the Internal Audit Function should revise its internal control system as follows:
a. Identify major areas of risk of material misstatement and/or fraud. As an example, the areas may
a. Identify major areas of risk of material misstatement and/or fraud. As an example, the areas may
include; late Audit reporting, identifying areas of risk of material misstatement such as making
include; late Audit reporting, identifying areas of risk of material misstatement such as making
timely required deposits to the reserve accounts including Residual Receipts, failing to review
timely required deposits to the reserve accounts including Residual Receipts, failing to review
prior year audit reports or audit findings, Proper and accurate reporting on a consistent and
prior year audit reports or audit findings, Proper and accurate reporting on a consistent and
ongoing basis to the most current HUD chart of accounts.
ongoing basis to the most current HUD chart of accounts.
b. Create or review existing controls to minimize risk, such as a system to review the financial
b. Create or review existing controls to minimize risk, such as a system to review the financial
statements general ledgers, bank reconciliations and all major fiscal management areas including
statements general ledgers, bank reconciliations and all major fiscal management areas including
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