Corrective Action Plans

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Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Medicaid Cluster Federal Assistance Listing Number: 93.778 Pass‐through: California Department of Health Care Services Award No. and Year: 2305CA5MAP, 2505CA5MAP,1946001347 A7, 2024/2025 Compliance Requirement: Eligibility...
Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Medicaid Cluster Federal Assistance Listing Number: 93.778 Pass‐through: California Department of Health Care Services Award No. and Year: 2305CA5MAP, 2505CA5MAP,1946001347 A7, 2024/2025 Compliance Requirement: Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: Solano County agrees that eligibility determinations and redeterminations including obtaining documentation and verifications should be performed annually to determine if individuals are eligible in accordance with the compliance requirements of the program. Medicaid Cluster – In-Home Supportive Services (IHSS) There are overdue redeterminations in our system due to the increasing need for IHSS services in Solano County and prioritization of the CDSS IHSS July 1, 2025 compliance mandate for 100% timely redeterminations for Community First Choice Option (CFCO) IHSS clients to prevent fiscal penalties. While we have reached 99% compliance for the IHSS CFCO clients, this has resulted in delays evaluating non-CFCO IHSS clients. In addition, we experienced uncovered caseloads related to Social Worker job transition or leave, more fair hearings and the growing complexity of our client population requiring more case management and re-evaluations throughout the year. We continue to review our IHSS workflow to develop efficiencies to maximize client service delivery. We monitor the performance of our IHSS Social Workers with a standard expectation of monthly client eligibility determinations and redeterminations. This performance management plan has contributed to successfully meeting several of our state compliance markers. Lastly, we continue to participate in State level discussions related to advocacy and increased IHSS administrative funding to support the growing number of IHSS clients. Medicaid Cluster – Medical Assistance The Employment and Eligibility division continues to monitor the performance of eligibility staff and build efficiencies into processes to increase processing timeliness. We recently developed a Customer Reporting Status dashboard that monitors all incomplete redeterminations and periodic reports for timeliness, which will be an effective tool for staff to monitor redetermination processing in order to meet our mandated compliance timelines. In addition, we are in the process of transitioning to a new business model for eligibility staff that perform annual redeterminations. We anticipate that this updated model will streamline workflows and enable staff to complete redeterminations with greater efficiency and timeliness. Responsible Individual(s): Dr. Cameron Kaiser, Chief Deputy Director, Health Officer Gwendolyn Gill, Health Services Administrator Alicia Jones, Deputy Director Health and Social Services Employment and Eligibility Programs Daniel Horel, Employment and Eligibility Administrator Anticipated Completion Date: July 1, 2026
2025-001 ALN 14.850 – Public Housing Operating Fund – Eligibility The Executive Director agrees with the finding as listed in the Schedule of Findings and Questioned Costs and will follow the Auditor's recommendations. Person Responsible for Correction of Finding: Ms. Khristian Allen, Executive Dire...
2025-001 ALN 14.850 – Public Housing Operating Fund – Eligibility The Executive Director agrees with the finding as listed in the Schedule of Findings and Questioned Costs and will follow the Auditor's recommendations. Person Responsible for Correction of Finding: Ms. Khristian Allen, Executive Director Projected Completion Date: June 30, 2026
Finding Number: 2025-043 Planned Corrective Action: Supervisors will be required to submit an email for employees whose scope of work requires access to the Florida Ryan White Portal (FL RW Portal) with all required documents to a designated inbox. The email and forms will be evaluated and approved ...
Finding Number: 2025-043 Planned Corrective Action: Supervisors will be required to submit an email for employees whose scope of work requires access to the Florida Ryan White Portal (FL RW Portal) with all required documents to a designated inbox. The email and forms will be evaluated and approved before the user is added to the FL RW Portal. Additionally, the employee gaining access or having access removed, will be logged with a time stamp and signoff of the employee providing/removing access. The onboarding/offboarding instructions will instruct all supervisors to submit an email for separated employees within one business day of separation requesting access removal from the FL RW Portal. In addition, there will be a process added to conduct quarterly reviews of user access to ensure employees have appropriate access. Anticipated Completion Date: June 1, 2026 Responsible Contact Person: Chrystal Thompson
Finding Number: 2025-040 Planned Corrective Action: Risk-Based Screenings – Death Master File (DMF): The Agency continues to make incremental improvements in its use of the SSA DMF during provider enrollment and re-enrollment. To achieve further progress and resolve this finding, the Agency is evalu...
Finding Number: 2025-040 Planned Corrective Action: Risk-Based Screenings – Death Master File (DMF): The Agency continues to make incremental improvements in its use of the SSA DMF during provider enrollment and re-enrollment. To achieve further progress and resolve this finding, the Agency is evaluating additional opportunities and taking steps to leverage the Enterprise Data Warehouse and other Medicaid infrastructure tools during these processes. The Agency will also explore the use of these tools to support realtime checks related to Risk-Based Screenings – NPPES and to enhance the review and resolution of LEIE and SAM matches. Anticipated Completion Date: June 2027 Responsible Contact Person: Nancy Massey
Finding Number: 2025-038 Planned Corrective Action: FDCF will evaluate its manual closure process and if necessary, make adjustments to ensure appropriate action is taken when a manual review is required. Anticipated Completion Date: December 31, 2026 Responsible Contact Person: Tera Bivens, Directo...
Finding Number: 2025-038 Planned Corrective Action: FDCF will evaluate its manual closure process and if necessary, make adjustments to ensure appropriate action is taken when a manual review is required. Anticipated Completion Date: December 31, 2026 Responsible Contact Person: Tera Bivens, Director of Programs & Policy Julie Reed, Chief of Policy
Finding Number: 2025-024 Planned Corrective Action: The Department shall review internal processes to identify mechanisms for documenting the deactivation of user access privileges. Anticipated Completion Date: 12/30/2026 Responsible Contact Person: Angela Carney, Audit & Compliance Consultant
Finding Number: 2025-024 Planned Corrective Action: The Department shall review internal processes to identify mechanisms for documenting the deactivation of user access privileges. Anticipated Completion Date: 12/30/2026 Responsible Contact Person: Angela Carney, Audit & Compliance Consultant
Finding Number: 2025-023 Planned Corrective Action: The Office of Information Technology Services (OITS) ACCESS application team that supports the FLORIDA system is in year four of a multi-year modernization initiative. By the end of 2027, all FLORIDA front-end functionality is expected to be availa...
Finding Number: 2025-023 Planned Corrective Action: The Office of Information Technology Services (OITS) ACCESS application team that supports the FLORIDA system is in year four of a multi-year modernization initiative. By the end of 2027, all FLORIDA front-end functionality is expected to be available through the ACCESS Management Portal, and staff will no longer have direct access to the FLORIDA mainframe. Given the current modernization progress and the planned elimination of direct mainframe access by the end of 2027, the Department acknowledges and accepts the residual risk during this transition. Anticipated Completion Date: 06/30/2028 Responsible Contact Person: Angela Carney, Audit & Compliance Consultant
Finding Number: 2025-031 Planned Corrective Action: As part of continuous process improvement, OIT is in the process of implementing additional improvement measures. Anticipated Completion Date: July 1, 2026 Responsible Contact Person: Sandy Barnes
Finding Number: 2025-031 Planned Corrective Action: As part of continuous process improvement, OIT is in the process of implementing additional improvement measures. Anticipated Completion Date: July 1, 2026 Responsible Contact Person: Sandy Barnes
Finding Number: 2025-030 Planned Corrective Action: As part of continuous process improvement, the Office of Information Technology (OIT) is in the process of implementing additional improvement measures. Anticipated Completion Date: August 31, 2026 Responsible Contact Person: Mark Stich
Finding Number: 2025-030 Planned Corrective Action: As part of continuous process improvement, the Office of Information Technology (OIT) is in the process of implementing additional improvement measures. Anticipated Completion Date: August 31, 2026 Responsible Contact Person: Mark Stich
Finding Number: 2025-028 Planned Corrective Action: FDCF will perform periodic monitoring and issue a policy refresher to ensure child support sanctions are timely reviewed and properly imposed. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Robert Hogan, Chief of Quality Man...
Finding Number: 2025-028 Planned Corrective Action: FDCF will perform periodic monitoring and issue a policy refresher to ensure child support sanctions are timely reviewed and properly imposed. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Robert Hogan, Chief of Quality Management Terri Lynch, Director of ESS Operations
Finding Number: 2025-027 Planned Corrective Action: FDCF continues the phased approach of modernizing its eligibility (ACCESS) system. The modernization of the FLORIDA legacy eligibility system started development in State Fiscal Year 2025-2026 and includes the operational analysis of the state’s da...
Finding Number: 2025-027 Planned Corrective Action: FDCF continues the phased approach of modernizing its eligibility (ACCESS) system. The modernization of the FLORIDA legacy eligibility system started development in State Fiscal Year 2025-2026 and includes the operational analysis of the state’s data exchange processes. Anticipated Completion Date: June 30, 2027 Responsible Contact Person: Chris Presnell, Director of Data and Information Technology
Finding Number: 2025-017 Planned Corrective Action: Beginning in the 2025-26 fiscal year, the Immunization Section implemented a policy requiring field staff to complete a compliance site visit to all providers in their assigned areas at least annually, rather than the two-year requirement establish...
Finding Number: 2025-017 Planned Corrective Action: Beginning in the 2025-26 fiscal year, the Immunization Section implemented a policy requiring field staff to complete a compliance site visit to all providers in their assigned areas at least annually, rather than the two-year requirement established by the Centers for Disease Control and Prevention (CDC) Vaccines for Children program. Spreadsheets were created to track assigned sites and due dates. Completion of compliance visits has also been added to field staff performance standards. The new policy also updated the process for conducting and documenting Orientation Site Visits (OSR). The program requires staff to conduct OSRs in person. Documentation is uploaded in CDC’s Provider Education, Assessment, and Reporting online system, and back-up documentation is uploaded to a FDOH shared drive and reviewed by the field staff’s supervisor. The supervisor maintains a spreadsheet with information on site visits and OSRs and follows up with staff on any missing documentation. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Tom Bendle
Finding Number: 2025-011 Planned Corrective Action: FCOM submitted a Legislative Budget Request to obtain funding for resources to implement an Identity Access Management tool. The estimated cost is $990,550. The estimated resolution date is June 30, 2027, provided FCOM receives funding to resolve t...
Finding Number: 2025-011 Planned Corrective Action: FCOM submitted a Legislative Budget Request to obtain funding for resources to implement an Identity Access Management tool. The estimated cost is $990,550. The estimated resolution date is June 30, 2027, provided FCOM receives funding to resolve the issue. Anticipated Completion Date: June 30, 2027 Responsible Contact Person: Roosevelt Petithomme/Wendy Castle
Finding Number: 2025-010 Planned Corrective Action: FCOM worked with its Employ Florida vendor and deployed a fix for the connectivity issue between Reconnect and Employ Florida in January 2025. A follow up meeting in April of 2025 where the issue was discussed did not reveal that the issue persiste...
Finding Number: 2025-010 Planned Corrective Action: FCOM worked with its Employ Florida vendor and deployed a fix for the connectivity issue between Reconnect and Employ Florida in January 2025. A follow up meeting in April of 2025 where the issue was discussed did not reveal that the issue persisted. In February 2026, the Auditor General notified FCOM that the fiscal year 2024/2025 audit revealed that the connectivity issue raised previously may still persist. FCOM is currently conducting an evaluation of the Auditor General’s sample and its larger datasets to isolate the variables causing these inconsistencies to determine if the issue has been resolved or if there is potentially a new connectivity issue to be resolved. The updated resolution will be completed by December 31, 2026. Anticipated Completion Date: December 31, 2026 Responsible Contact Person: Roosevelt Petithomme/Wendy Castle
Finding Number: 2025-009 Planned Corrective Action: FCOM is working with the development team to remediate the listed security controls and will develop the necessary changes by June 30, 2026. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Roosevelt Petithomme/Paul Forrester
Finding Number: 2025-009 Planned Corrective Action: FCOM is working with the development team to remediate the listed security controls and will develop the necessary changes by June 30, 2026. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Roosevelt Petithomme/Paul Forrester
Finding Number: 2025-008 Planned Corrective Action: In the 2026 Legislative Session, FCOM submitted a Legislative Budget Request to obtain funding for resources to implement an Identity Access Management tool which would resolve this finding. The estimated cost is $990,550. The estimated resolution ...
Finding Number: 2025-008 Planned Corrective Action: In the 2026 Legislative Session, FCOM submitted a Legislative Budget Request to obtain funding for resources to implement an Identity Access Management tool which would resolve this finding. The estimated cost is $990,550. The estimated resolution date is June 30, 2027, provided FCOM receives funding to resolve the issue. Anticipated Completion Date: June 30, 2027 Responsible Contact Person: Roosevelt Petithomme
Finding Number: 2025-007 Planned Corrective Action: FCOM submitted a Legislative Budget Request to obtain funding for resources to ensure system code changes are corrected; however, FCOM is continuing development of the functional design documentation. The estimated resolution date is June 30, 2027....
Finding Number: 2025-007 Planned Corrective Action: FCOM submitted a Legislative Budget Request to obtain funding for resources to ensure system code changes are corrected; however, FCOM is continuing development of the functional design documentation. The estimated resolution date is June 30, 2027. Anticipated Completion Date: June 30, 2027 Responsible Contact Person: Roosevelt Petithomme/Paul Forrester
Finding Number: 2025-003 Planned Corrective Action: To address this finding, FNW immediately implemented a temporary solution. On or about September 8, 2025, FNW created a ticket to commence work on a permanent solution to address the audit finding. The solution deployed on March 18, 2026. Anticipat...
Finding Number: 2025-003 Planned Corrective Action: To address this finding, FNW immediately implemented a temporary solution. On or about September 8, 2025, FNW created a ticket to commence work on a permanent solution to address the audit finding. The solution deployed on March 18, 2026. Anticipated Completion Date: March 18, 2026 Responsible Contact Person: Terricka Washington, Division of Food, Nutrition and Wellness Information Office/LaSharonté Williams-Potts, Assistant Division Director
Corrective Action Plan 2025-002: This finding is related to the transition to a new Jenzabar One (J1) ERP system. The Jenzabar Financial Aid (JFA) module, while now integrated into the broader J1 suite, remains a stand-alone solution rather than a fully native component. As a result, Ottawa Universi...
Corrective Action Plan 2025-002: This finding is related to the transition to a new Jenzabar One (J1) ERP system. The Jenzabar Financial Aid (JFA) module, while now integrated into the broader J1 suite, remains a stand-alone solution rather than a fully native component. As a result, Ottawa University needed to modify its financial aid refund disbursement processes to ensure accurate and efficient data flow between systems. These adjustments created challenges in achieving the timely distribution of student refunds. The primary issue involved the timely processing of PLUS Loan refunds. Parent IDs for these refunds were extracted from financial aid data in JFA and established as individual vendors in J1. These IDs then needed to be properly linked to the corresponding student before any parent refunds could be issued. To address this, Financial Aid has designated staff to oversee the creation and linking of parent IDs in J1 to ensure timely processing. Additionally, reports have been developed to identify accounts eligible for refunds, helping to ensure compliance with the 14-day requirement. The Accounting Department also encountered challenges related to vendor setup and the ability to process student refunds in batches. To address these issues, we collaborated with the J1 support team and IT to customize the system, ensuring that student refund checks could be processed and formatted in accordance with bank specifications. While we were not initially prepared for these challenges and had to adapt throughout the process, a solution has since been implemented. As a result, check printing has become an efficient and streamlined operation. The Student Accounts Receivable Office, Controller’s Office, Financial Aid, and IT departments are actively collaborating to establish a more structured and efficient process for managing Federal Student Aid. The first step has been to implement a weekly workflow with clearly defined responsibilities and completion timelines as follows: Financial Aid posts all activity at the beginning of the week, followed by Student Accounts generating credit balance refund reports and initiating student refunds. Accounting then completes the process by issuing refunds to students via check or direct deposit. In addition, Student Accounts and IT are working to develop a datespecific report to identify students with current financial aid disbursements who have outstanding credit balances. This detective control report will be reviewed weekly, and refunds will be processed in accordance with the established workflow. The departments are also developing a detailed Accounts Receivable Aging Report to help the Receivables team more effectively identify any students who have a credit balance. This effort is intended to ensure full compliance with the 14-day requirement outlined in the Federal Student Aid Handbook. Anticipated Completion Date: June 30, 2026 Contact Person: Heather Long, Director of Student Accounts
Corrective Action Plan 2025‐001: The Registrar and the IT department are working together to ensure timely and accurate data is being transmitted on a regular schedule to the Clearinghouse as needed. When date determination exceptions occur (e.g., degrees being conferred after initial reporting or w...
Corrective Action Plan 2025‐001: The Registrar and the IT department are working together to ensure timely and accurate data is being transmitted on a regular schedule to the Clearinghouse as needed. When date determination exceptions occur (e.g., degrees being conferred after initial reporting or withdrawal dates being retroactively determined for administrative purposes), the Registrar’s Office, IT, and Financial Aid will work together to determine the appropriate date adjustments needed to manually update the Clearinghouse with the correct information if needed as quickly as possible. Anticipated Completion Date: June 30, 2026 Contact Person: Julie McAdoo, University Registrar
Coronavirus State and Local Fiscal Recovery Funds 21.027 Recommendation: CLA recommends that management reinforce and consistently apply key control procedures requiring documented review and approval of all program invoices prior to payment. Management should ensure that reviews explicitly address ...
Coronavirus State and Local Fiscal Recovery Funds 21.027 Recommendation: CLA recommends that management reinforce and consistently apply key control procedures requiring documented review and approval of all program invoices prior to payment. Management should ensure that reviews explicitly address allowability, eligibility and within the period of performance under the program and that evidence of such review is retained in accordance with record retention requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management will enforce the internal controls in place to ensure full compliance. Name of the contact person responsible for corrective action: Maria Giaimo, CFO Planned completion date for corrective action plan: June 30, 2026
Management agrees with this finding. The instance in which a Pell Grant disbursement was not reported to the U.S. Department of Education Common Origination and Disbursement (COD) System within the required 15 calendar days was due to the student not answering the high school completion question on ...
Management agrees with this finding. The instance in which a Pell Grant disbursement was not reported to the U.S. Department of Education Common Origination and Disbursement (COD) System within the required 15 calendar days was due to the student not answering the high school completion question on the Free Application for Federal Student Aid (FAFSA), which relates to Ability to Benefit (ATB) eligibility. To address this issue and prevent recurrence, we have implemented an additional control. We now identify students who have been awarded a Pell Grant but have not answered the FAFSA high school completion question. For these students, an ATB requirement is posted on RRAAREQ, which prevents the Pell Grant from disbursing until the FAFSA question has been resolved. This process change ensures that Pell Grant funds will not disburse until the FAFSA high school completion question is completed, allowing the Pell Grant record to successfully extract to COD within the required reporting timeframe. This system update corrects the condition identified in the audit finding and strengthens our internal controls to ensure compliance with federal reporting requirements.
A. Remediation of Identified Files For participants who are no longer active in the WIC program, no further action will be taken, as the certification period has concluded. For participants who remain active and whose files lack a signed WIC Agreement of Rights and Responsibilities, an “alert” will ...
A. Remediation of Identified Files For participants who are no longer active in the WIC program, no further action will be taken, as the certification period has concluded. For participants who remain active and whose files lack a signed WIC Agreement of Rights and Responsibilities, an “alert” will be placed in the WIC system to ensure the required signature is obtained at the participant’s next scheduled appointment. The signed agreement will be retained in the participant’s certification file in accordance with documentation requirements. B. Staff Reinforcement and Training The WIC Director meets with staff weekly and will formally address the requirement to obtain and retain a signed WIC Agreement of Rights and Responsibilities annually. Staff will be reminded that a certification file is not considered complete unless all required eligibility documentation, including the signed agreement, is present. C. Strengthened Supervisory Review Control (Monitoring Control) Beginning immediately, the WIC Director (or designated supervisory staff) will implement a documented monitoring control to ensure completeness of eligibility documentation: 1. On a monthly basis, supervisory staff will select a sample of newly certified and recertified participant files. 2. The review will verify that all required eligibility documentation is present, including: o Categorical determination o Proof of residency o Income documentation o Nutritional risk documentation o Signed WIC Agreement of Rights and Responsibilities 3. Evidence of supervisory review (e.g., initials, checklist, or review log) will be retained. 4. Any deficiencies identified during internal monitoring will be corrected promptly, and trends will be discussed with staff. This monitoring control is designed to ensure ongoing compliance with federal and state eligibility documentation requirements and to prevent recurrence of the deficiency.
The District appreciates the opportunity to respond to the audit finding regarding inconsistencies between Title I rank order and the allocation of funds based on low-income student percentages for the 2024-2025 fiscal year. Our review indicates that the variance in allocations resulted from a budge...
The District appreciates the opportunity to respond to the audit finding regarding inconsistencies between Title I rank order and the allocation of funds based on low-income student percentages for the 2024-2025 fiscal year. Our review indicates that the variance in allocations resulted from a budget decision to provide additional Title I funding to Bowling Green Elementary to support after-school programming, without fully accounting for per-pupil allocation. Historically, Bowling Green Elementary has served one of the highest concentrations of students from low-income families in the District, and the additional allocation was intended to ensure continuity of extended learning opportunities for students with significant academic need. While this decision was grounded in student need, the District recognizes that the additional funds were not fully reconciled with updated poverty data and required rank-order calculations. The District has demonstrated compliance with rank and serve requirements in prior years; however, to prevent recurrence, we are strengthening our internal controls. Beginning immediately, the District will implement a structured monthly review of Title I school allocations involving the Title I Program Specialist, the Finance Director, and the Deputy Superintendent to ensure that the 2025-2026 allocations align with current poverty data and PSES calculations. Additionally, the District will seek guidance from the Florida Department of Education Title I Office to confirm that our procedures fully meet all regulatory expectations. The District is confident that these corrective actions will ensure full compliance in 2025-2026 moving forward and will strengthen the integrity of our allocation processes.
U.S. Department of Education Maranatha Baptist University (the University) respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit period: July 01, 2024 to June 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The...
U.S. Department of Education Maranatha Baptist University (the University) respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit period: July 01, 2024 to June 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT Our audit did not disclose any matters required to be reported in accordance with Government Auditing Standards. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Education 2025-001 Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.063 & 84.268 Recommendation: We recommend that the University maintain documentation of both formal and informal award notifications in their financial aid software to ensure all necessary communications are made. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University Financial Aid Office will add a step in the awarding process to verify that award emails are sent and are documented in the system. Name of the contact person responsible for corrective action: Donald Donovan, Chief Financial Officer Planned completion date for corrective action plan: June 30, 2026 *** If the U.S Department of Education has questions regarding this plan, please call Donald Donovan, Chief Financial Officer, at 920-206-2314.
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