Corrective Action Plans

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Annual and Aggregate Loan Limits The University acknowledges the finding regarding the awarding of unsubsidized loan funds in excess of annual limits without adequate supporting documentation. We recognize that federal regulations require either a valid PLUS denial or fully documented professional j...
Annual and Aggregate Loan Limits The University acknowledges the finding regarding the awarding of unsubsidized loan funds in excess of annual limits without adequate supporting documentation. We recognize that federal regulations require either a valid PLUS denial or fully documented professional judgment to support additional unsubsidized eligibility. Corrective Actions 1. Strengthened Documentation Requirements: Effective immediately, financial aid staff will maintain complete professional judgment documentation, including the rationale, supporting evidence, and approval, in the student’s file before any additional unsubsidized loan is awarded. 2. Verification Controls: A mandatory checklist has been implemented to ensure that a PLUS denial or documented professional judgment is obtained and reviewed prior to disbursement of any loan amount exceeding standard limits. 3. Staff Training: The Office of Financial Aid will conduct targeted training to reinforce Title IV loan limit rules and proper documentation standards. 4. Ongoing Monitoring: Supervisory review will be performed on all professional judgment decisions and on any loan increases exceeding the standard $2,000 annual limit. The University believes these corrective measures will address the root cause of the finding and ensure full compliance with federal loan regulations going forward.
Finding 2025-004 Finding Summary: Elko County School District did not have sufficient internal controls to ensure eligibility determinations of Title I fund amounts disbursed were being appropriately followed. Corrective Action Plan: The grants department will update allocation procedures to ensure ...
Finding 2025-004 Finding Summary: Elko County School District did not have sufficient internal controls to ensure eligibility determinations of Title I fund amounts disbursed were being appropriately followed. Corrective Action Plan: The grants department will update allocation procedures to ensure equitable distribution of Title I funds to all eligible schools in rank order by low-income student count. Responsible Individual: Megan Cox Grant Manager Anticipated Completion Date: June 2026
Corrective Action: The University agrees with the findings. The project Directors will continue to validate data input into the system prior to the submission of the APR. We will establish a cut-off date for rolling the system fmward to prevent these administrative clerical errors. Contact Person: M...
Corrective Action: The University agrees with the findings. The project Directors will continue to validate data input into the system prior to the submission of the APR. We will establish a cut-off date for rolling the system fmward to prevent these administrative clerical errors. Contact Person: Mikael Davis, SSS Director And Dr Ferguson Gregg, Upward Bound Director Anticipated Completion Date: June 15, 2026
BAY BRIDGE CORPORATION 2220 OXFORD STREET BERKELEY, CALIFORNIA 94704 (510) 841-4410 CORRECTIVE ACTION PLAN March 31, 2026 Cognizant or Oversight Agency for Audit: Department of Housing and Urban Development Bay Bridge Corporation respectfully submits the following corrective action plan for the year...
BAY BRIDGE CORPORATION 2220 OXFORD STREET BERKELEY, CALIFORNIA 94704 (510) 841-4410 CORRECTIVE ACTION PLAN March 31, 2026 Cognizant or Oversight Agency for Audit: Department of Housing and Urban Development Bay Bridge Corporation respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Lindquist von Husen & Joyce LLP 301 Howard Street, Suite 850 San Francisco, CA 94105 Audit period: July 1, 2024, to June 30, 2025 The findings from the June 30, 2025, 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 None noted. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS 2025-001 Compliance over Eligibility Requirements to Perform Annual Recertification - Assistance Listing No. 14.181. Program –Supportive Housing for Persons with Disabilities Significant Deficiency Recommendation: Bay Bridge should develop an operating plan in order to ensure that recertifications are performed timely each year, despite of staff shortages. Action Taken: We hired a new Property Manager for Bay Bridge Apartments, who has worked diligently to complete outstanding recertifications and this property is back on track. All recertifications are now current with one exception due to a lack of tenant cooperation which is being properly managed with legal action. To ensure that staff changes and vacancies do not result in late recertifications in the future, we have employed Property Operations Specialists (roving personnel) to provide coverage if there is staff turnover. We have also increased oversight by the Regional Manager to ensure roving staff remain on track and that recertifications are completed timely. Additionally, senior leadership at the John Stewart Company has implemented enhanced tracking of recertifications across the full portfolio and conducts monthly progress meetings with the management team to monitor compliance, identify risks early, and ensure accountability. We are confident that these corrective actions will result in sustained improvement and ongoing compliance. If the Department of Housing and Urban Development has questions regarding this plan, please call Zelda Ryan, Corporate Controller, at (510) 841-4410 x304#. Sincerely, Eric Knecht, CFO Resources for Community Development
VERNON STREET HOUSING INC 2220 OXFORD STREET BERKELEY, CALIFORNIA 94704 (510) 841-4410 CORRECTIVE ACTION PLAN March 31, 2026 Cognizant or Oversight Agency for Audit: Department of Housing and Urban Development Vernon Street Housing, Inc. respectfully submits the following corrective action plan for ...
VERNON STREET HOUSING INC 2220 OXFORD STREET BERKELEY, CALIFORNIA 94704 (510) 841-4410 CORRECTIVE ACTION PLAN March 31, 2026 Cognizant or Oversight Agency for Audit: Department of Housing and Urban Development Vernon Street Housing, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Lindquist von Husen & Joyce LLP 301 Howard Street, Suite 850 San Francisco, CA 94105 Audit period: July 1, 2024, to June 30, 2025 The findings from the June 30, 2025, 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 None noted. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS 2025-001 Compliance over Eligibility Requirements to Perform Annual Recertification - Assistance Listing No. 14.181. Program –Supportive Housing for Persons with Disabilities Significant Deficiency Vernon Street Housing, Inc. should develop an operating plan in order to ensure that recertifications are performed timely each year, despite of staff shortages. Action Taken: Unanticipated staff shortages created gaps in performance of annual recertifications at this location. New staff has since been hired in the Regional Manager role and the Director role. Both new employees are providing greater oversight and visiting the property regularly to track progress. In addition to our permanent staffing efforts, we have deployed a Property Operations Specialist to bring recertifications current at Vernon Street Housing This specialist is focused specifically on compliance tasks and critical deadlines. Additionally, senior leadership at the John Stewart Company has implemented enhanced tracking of recertifications across the full portfolio and now conducts monthly progress meetings with management team to monitor compliance, identify risks early, and ensure accountability. We are confident that these corrective actions will result in sustained improvement and ongoing compliance. If the Department of Housing and Urban Development has questions regarding this plan, please call Zelda Ryan, Corporate Controller, at (510) 841-4410 x304#. Sincerely, Eric Knecht, CFO Resources for Community Development
Corrective Action Plan For the Year Ended June 30, 2025 NorthamptoN CouNty Finance Department 9467 Hwy 305 Jackson, North Carolina 27845 Leslie Edwards Finance Director Finding 2025-009 Inaccurate Information Entry Name of contact: Sammantha Thomas, Program Manager Corrective Action: Proposed Comple...
Corrective Action Plan For the Year Ended June 30, 2025 NorthamptoN CouNty Finance Department 9467 Hwy 305 Jackson, North Carolina 27845 Leslie Edwards Finance Director Finding 2025-009 Inaccurate Information Entry Name of contact: Sammantha Thomas, Program Manager Corrective Action: Proposed Completion Date: Corrective Actions for finding 2025-010 also apply to State Award findings. Section IV - State Award Findings and Question Costs Section III - Federal Award Findings and Question Costs The program manager held a staff meeting to discuss audit results and all errors. The Program Manager will be requiring policy training for all Medicaid supervisors and caseworkers. The program manager will have another staff meeting to discuss new procedures for caseworkers and supervisors. New actions for caseworkers will include a new detailed checklist that will be reviewed by a lead worker or supervisor when requesting information for cases that result in a termination, reduction or denial. Additionally, all caseworkers will be responsible for generating a report of all outstanding and overdue reviews and will prioritize cases nearing compliance deadlines. New actions for Supervisors will include a review of all cases completed by new employees. Currently second party reviews are being completed on five cases weekly per caseworker, however, going forward this will be increased to 8-10 cases weekly per caseworker. Additionally, supervisors will be responsible for implementing a real-time tracking log for review due dates, review timeliness of these reports daily, and supervisors will meet with the Program Manager monthly to report timeliness metrics. Supervisors and staff will be required to complete yearly policy training provided by the Program Manager to ensure they are clear on review timelines and accuracy. A meeting with all staff and supervisors was held on 2/25/2026 to discuss the findings of the Audit. All trainings will be completed no later than 3/31/2026. All new requirements by the program manager will be implemented immediately. 156
Uniform Guidance Financial and Compliance Audit-June 30, 2025, Ending Fiscal Year Paine College has developed a structured corrective action plan to address findings (2025- 001, 2025-002, 2025-003, 2025-004, and 2025-005) identified in the Uniform Guidance Financial and Compliance Audit. The institu...
Uniform Guidance Financial and Compliance Audit-June 30, 2025, Ending Fiscal Year Paine College has developed a structured corrective action plan to address findings (2025- 001, 2025-002, 2025-003, 2025-004, and 2025-005) identified in the Uniform Guidance Financial and Compliance Audit. The institution is prioritizing the strengthening of internal controls, the improvement of financial oversight, and the enhancement of compliance monitoring to ensure responsible stewardship offederal funds and long-term institutional stability. The corrective action outlines each audit finding and the steps the College is taking to resolve the identified concerns. The second (2025-002) finding pertains to compliance with federal eligibility requirements for the TRIO Upward Bound Program. Federal regulations require at least two-thirds of program participants to be both low-income and first-generation college students. The audit identified that the program fell below the required threshold. To address this issue, the College is strengthening participant eligibility verification procedures and implementing additional monitoring to ensure compliance throughout the program year. Recruitment strategies are also being enhanced to increase the number of eligible participants served by the program. In addition, staff will continue to receive targeted training to ensure accurate eligibility documentation and consistency between program records and federal reporting requirements. Corrective Action 2025-002: Strengthen participant eligibility verification, improve recruitment of eligible participants, enhance APR reporting accuracy, and provide compliance training for TRIO staff. Target resolution 2025-2026 Program Year
Uniform Guidance Financial and Compliance Audit-June 30, 2025, Ending Fiscal Year Paine College has developed a structured corrective action plan to address findings (2025- 001, 2025-002, 2025-003, 2025-004, and 2025-005) identified in the Uniform Guidance Financial and Compliance Audit. The institu...
Uniform Guidance Financial and Compliance Audit-June 30, 2025, Ending Fiscal Year Paine College has developed a structured corrective action plan to address findings (2025- 001, 2025-002, 2025-003, 2025-004, and 2025-005) identified in the Uniform Guidance Financial and Compliance Audit. The institution is prioritizing the strengthening of internal controls, the improvement of financial oversight, and the enhancement of compliance monitoring to ensure responsible stewardship offederal funds and long-term institutional stability. The corrective action outlines each audit finding and the steps the College is taking to resolve the identified concerns. Corrective Action 2025-005: Administrative and Fiscal Affairs 1235 Fifteenth Street, Augusta, GA 30901 Implement the Return to Title IV monitoring system, weekly credit balance tracking, counseling verification procedures, and strengthen coordination between Financial Aid, Registrar, and Business Office Target resolution: Spring-Summer 2026
Finding 2025 - 001 - U.S. Department of Education (USD), Title IV Student Financial Aid Programs (material weakness): Information on the federal program - (Federal Award Identification): - Federal Pell Grant Program, FAL No. 84.063, June 30, 2025; Federal Supplemental Opportunity Grant Program, FAL ...
Finding 2025 - 001 - U.S. Department of Education (USD), Title IV Student Financial Aid Programs (material weakness): Information on the federal program - (Federal Award Identification): - Federal Pell Grant Program, FAL No. 84.063, June 30, 2025; Federal Supplemental Opportunity Grant Program, FAL No. 84.007, June 30, 2025; Federal Work-Study Program, FAL No. 84.033, June 30, 2025; Federal Direct Student Loan Program, FAL No. 84.268, June 30, 2025; Federal Teacher Education Assistance for College (TEACH), FAL No. 84.379, June 30, 2025. Institutions must determine a student's financial need by subtracting the expected family contribution and estimated financial assistance from the cost of attendance. 34 CFR 668.2 and 34 CFR 637.S(a). 1. Corrective Action Description The College has engaged a financial aid consultant to support the development of cost-of-attendance budgets and ensure they align with industry best practices, thereby making improvements to the College's financial aid operating system. After evaluating the auditors' sample of forty students, the College confirmed that no instances of over/under awarding occurred. There were clarifications and changes made to the initial cost of attendance budgets provided to the auditors that led to the questioned cost. The College will implement ongoing monitoring each semester to further enhance operational efficiency and effectiveness. The cost of attendance budgets has been uploaded into the College's financial aid system to prevent the recurrence of this issue for the current and future years. a. Responsible Person and Department Diana Knighton Senior Vice President, Finance and Business Administration Miles College 5500 Myron Massey Boulevard Fairfield, AL 3506 (205) 929-1442 dknighton@miles.edu b. Implementation Timeline January 18, 2026, for the spring semester c. Planned Preventive Measures The College hired a financial aid consultant to assist the financial aid Director with best practices and to make modifications to the ERP system to provide better operating efficiency and effectiveness. d. Disagreement with the Finding None
2025-001: Incorrect Direct Loans Disbursement Amount - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, Grant Period - Year Ended August 31, 2025 Condition Found During our student file testing we noted two students out of forty were disbursed the incor...
2025-001: Incorrect Direct Loans Disbursement Amount - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, Grant Period - Year Ended August 31, 2025 Condition Found During our student file testing we noted two students out of forty were disbursed the incorrect Direct Loan amount. Based on the student’s enrollment status and need, the University over awarded the students by $1,229. We consider this error in awarding to be an instance of noncompliance of the Eligibility Compliance Requirement. Corrective Action Plan Financial Aid office will make sure the correct amount is awarded based on the student enrollment status and need of the student. EWU will make the proper adjustments to the Direct Subsidized Loan to reflect the correct amount for the two students. Responsible Person for Corrective Action Plan Director of Financial Aid Cesar Campos Implementation Date of Corrective Action Plan March 06, 2026
Finding 2025-003 – Incomplete Eligibility Documentation Management agrees with the recommendation and will implement stronger processes to ensure that records confirming the eligibility of program participants are obtained and properly maintained. Specifically, all program staff documenting client e...
Finding 2025-003 – Incomplete Eligibility Documentation Management agrees with the recommendation and will implement stronger processes to ensure that records confirming the eligibility of program participants are obtained and properly maintained. Specifically, all program staff documenting client eligibility will receive related training on eligibility requirements and best practices for related recordkeeping. While the organization will take these steps to help prevent reoccurrence of this finding, management also states that it directly sought and followed guidance from the program pass-through entity specific to client eligibility which was deemed in this audit to be inconsistent with requirements guiding the federal program. At the time of writing, this matter is being evaluated by the pass-through entity with further guidance forthcoming. Therefore, in addition to the steps outlined above, the organization will also further verify any guidance received from pass-through entities or other monitoring agencies to ensure its internal processes align directly and specifically with all requirements of the federal program. The contact persons for the Corrective Action Plan are Bill Threlkeld, VP of Community Resources Partnerships; Ted Lewis, EVP of Operations and Information Technology (IAT Co-Chair); and Aaron Hernandez, Sr. Director, Finance (IAT Co-Chair). The anticipated completion date is June 30, 2026. In addition to these specific steps, Cornerstones has strengthened its compliance review operations overall through the addition of a staff member who will focus primarily on compliance issues across the organization. Cornerstones has also formed an Internal Audit Team (IAT) comprised of organizational leadership that will provide objective assurance that the organization operates in full alignment with laws, regulations, contract provisions, and ethical standards.
Finding 2025-001 – Incomplete Eligibility Documentation (Repeat Finding 2024-001) Management agrees with the recommendation and will implement stronger processes to ensure that records confirming the eligibility of program participants are obtained and properly maintained. Specifically, all program ...
Finding 2025-001 – Incomplete Eligibility Documentation (Repeat Finding 2024-001) Management agrees with the recommendation and will implement stronger processes to ensure that records confirming the eligibility of program participants are obtained and properly maintained. Specifically, all program staff documenting client eligibility will receive related training, both internally as well as from identified external sources. Accordingly, program staff attended a training on case management provided by an external partner in November 2025. Internal training will center on the Employment and Training Eligibility Determination form developed by the program pass-through entity in March 2026. This document provides a detailed checklist of the specific information required to verify client eligibility prior to delivering program services. Finally, the organization will work with its external partners (PTEs, monitoring agencies, etc.) to ensure that requirements are consistently stated across all pertinent organizations and described in common nomenclature to avoid confusion and/or inadvertent omissions, which have been key factors contributing to the reoccurrence of this finding in FY25. The contact persons for the Corrective Action Plan are Lacy Stokes, VP of Family Empowerment and Self-Sufficiency; Ted Lewis, EVP of Operations and Information Technology (IAT Co-Chair); and Aaron Hernandez, Sr. Director, Finance (IAT Co-Chair). The anticipated completion date is May 31, 2026.
Finding 2025-009-U.S. Department of Education (ED) TRIO Cluster Programs (significant deficiency) Information on the federal program-Educational Talent Search, FAL 84.044A This memorandum serves as management’s response to the audit finding regarding internal control weaknesses in participant eligib...
Finding 2025-009-U.S. Department of Education (ED) TRIO Cluster Programs (significant deficiency) Information on the federal program-Educational Talent Search, FAL 84.044A This memorandum serves as management’s response to the audit finding regarding internal control weaknesses in participant eligibility documentation for the Educational Talent Search Program under 34 CFR § 643.3. Acknowledgment of Finding Management acknowledges the condition identified in which two participants’ applications lacked incorrect information to verify age eligibility requirements. Management notes, this condition reflects a perceived control weakness that may impact compliance with TRIO Talent Search Program requirements. Management Response During the initial application process, parent and student data is entered into a system-generated application. Management acknowledges that, in instances where inaccurate information is entered (e.g., date of birth), established procedures require verification against official documentation, such as the student’s transcript. Supporting documentation for Shayla Adams and Madison Wallace is provided as evidence. Upon identifying omissions or incorrect information during the review process, management verifies the applicants’ information directly with the participants’ school as part of the secondary review process. Official documentation is obtained and reviewed, and the verified date of birth is recorded as documented on the students’ official transcripts and maintained in the participant files. The applicants’ information is entered correctly in the student database (Blumen) prior to acceptance, ensuring compliance with eligibility documentation requirements under 34 CFR § 643.3. Management is committed to addressing this issue promptly and strengthening internal controls to ensure full compliance with federal regulations. Procedures governing participant intake, eligibility verification, documentation retention, and supervisory oversight will be consistently monitored. These measures include standardized processes, increased staff accountability, and ongoing monitoring to maintain program integrity. Corrective Action Plan 1. Standardized Eligibility Verification Process A comprehensive eligibility checklist will be implemented and required for all participant files to ensure consistent documentation collection and verification prior to acceptance. Before an acceptance letter is provided to students, and the information is entered into Blumen, birthdates will be checked by the school transcript. Responsible Party: Assistant Director and Program Director Implementation Date: Immediately upon receiving the application 2. Secondary Review and Approval Control A mandatory secondary review process will continue. Participants’ acceptance will not be approved until all eligibility documentation is verified as accurate complete. Responsible Party: Assistant Director Accountable: Program Director Implementation Date: Immediate 3. Staff Training and Procedure Reinforcement All staff will participate in mandatory training on eligibility requirements and documentation standards. Written procedures and required intake documentation will be provided to reinforce compliance expectations. Responsible Party: Assistant Director and Program Director Accountable: Program Director Implementation Date: Monthly 4. Documentation Tracking System Management will implement a tracking procedure to identify and monitor missing or incomplete documentation, ensuring deficiencies are resolved prior to participant approval. Responsible Party: Assistant Director and Senior Counselors Accountable: Program Director Implementation Date: Immediately upon receiving the application 5. Ongoing Monitoring and Internal Reviews Quarterly internal file reviews will be conducted to assess compliance with eligibility requirements. Findings will be documented and corrective actions enforced. Responsible Party: Assistant Director and Senior Counselor Accountable : Program Director Implementation Date: Quarterly 6. Documentation Retention Controls Uniform file management protocols will be established to ensure all eligibility documentation is properly maintained, organized, and readily accessible. Responsible Party: Assistant Director Accountable Program: Director Implementation Date: Ongoing Conclusion Management takes this matter seriously and is committed to ensuring that all corrective actions are fully implemented within the stated timeframes. These measures are designed to strengthen internal controls, ensure compliance with federal requirements, and enhance the integrity of participant eligibility determinations. The College has already initiated corrective action by hiring entirely new staff in key positions and is committed to fostering a culture of compliance through rigorous procedures and training. 1. Staff Expertise: Financial Aid team members are becoming certified in the enterprise resource program module, specifically related to financial aid, as a first step. 2. SOP Implementation: The core of this plan involves the creation of seven new or updated Standard Operating Procedures (SOPs) (as highlighted above) to standardize compliance activities and reduce reliance on individual employee experience. 3. Proactive Monitoring: We are implementing mandatory monthly and quarterly reconciliation and audit reports to ensure adherence to timelines and documentation requirements, moving from reactive to proactive compliance management. 4. Cross-Training: Training will be conducted across multiple departments (Financial Aid, Business Office, Registrar) to ensure shared understanding and accountability for Title IV compliance.
Finding 2025-001 U.S. Department of Education (USDE), Title IV Student Financial Aid Programs – Satisfactory Academic Progress (material weakness): Management’s Response and Corrective Action Plan Tougaloo College acknowledges the findings identified in the audit for the fiscal year ending June 30, ...
Finding 2025-001 U.S. Department of Education (USDE), Title IV Student Financial Aid Programs – Satisfactory Academic Progress (material weakness): Management’s Response and Corrective Action Plan Tougaloo College acknowledges the findings identified in the audit for the fiscal year ending June 30, 2025, regarding Finding 2025-001 (Material Weakness). We recognize the gravity of the systemic issues related to the monitoring of Satisfactory Academic Progress (SAP) and the associated questioned costs of $346,764.00. The College is committed to full compliance with 34 CFR 668.34 and is implementing the following corrective actions to ensure the integrity of our Title IV Student Financial Aid Programs. • Automation and System Integration: The College is transitioning from manual SAP monitoring to an automated tracking system within our Student Information System (SIS). This will ensure that academic standing—specifically GPA and completion rates are calculated systematically at the end of each Spring Semester. • Audit of Appeal Documentation: We are establishing a centralized digital repository for all SAP appeals. Effective immediately, no Title IV funds will be disbursed to students on financial aid probation without a documented, approved appeal and a corresponding academic plan on file. • Staff Training and Accountability: The Office of Financial Aid will undergo mandatory training focused specifically on federal SAP criteria. We have revised our internal "Check and Balance" protocol, requiring a secondary review by the Director of Financial Aid before any student failing SAP is cleared for disbursement. • Annual Policy Review: In alignment with the Auditor’s Recommendation, Tougaloo College will conduct a comprehensive annual evaluation of all students. This evaluation will be reconciled against the Registrar’s records to ensure data consistency. • We have updated our SAP policy to allow us to review at end of each Spring The College has already begun the look-back process to review the eligibility of the 16 students identified in the sample. We anticipate that the new automated monitoring and revised internal controls will be fully operational by the start of the Fall 2026 semester to prevent any further repeat findings.
The District acknowledges the audit finding related to documentation of suspension and debarment verification for vendors participating in federally funded programs. While no vendors reviewed were suspended or debarred and no questioned costs were identified, the District agrees that formal document...
The District acknowledges the audit finding related to documentation of suspension and debarment verification for vendors participating in federally funded programs. While no vendors reviewed were suspended or debarred and no questioned costs were identified, the District agrees that formal documentation of this verification should be maintained in the project file. To address this finding, the District has prepared a Standard Operating Procedure titled “Procedure for Debarment Verification for Federally Funded Contracts.” The procedure requires that at the time of contract review for federally funded contracts, prior to contract award, Finance and Business Services staff perform a search in SAM.gov to verify the contractor is not debarred or suspended from receiving federal funds. The result of the debarment search will be saved in the Finance and Business services project files. If the contractor is not registered with SAM.gov, a signed Non-Debarment Certification Form will be obtained from the selected vendor by the Project Manager prior to contract execution. The signed certification form will be saved in the Project Manager’s files along with the executed contract. The District is in the process of reviewing and documenting the debarment search for all vendors who received federal funding under this program. While the comprehensive review is in progress, all requests for federal funds will have the debarment search documentation verified before the request is submitted.
Management agrees with the finding and has indicated that corrective actions will be implemented to improve monitoring and timeliness of R2T4 returns. Management’s corrective action plan is included in the accompanying schedule.
Management agrees with the finding and has indicated that corrective actions will be implemented to improve monitoring and timeliness of R2T4 returns. Management’s corrective action plan is included in the accompanying schedule.
The organization has implemented additional levels of review and pre­screening of slide patient data to ensure accuracy and that the data is complete. Routine reviews done by front desk supervisors will be further documented in order to provide additional training to staff as needed. Results of mont...
The organization has implemented additional levels of review and pre­screening of slide patient data to ensure accuracy and that the data is complete. Routine reviews done by front desk supervisors will be further documented in order to provide additional training to staff as needed. Results of monthly audits performed by service line leaders will be reported to senior leadership. An internal audit will be done by the compliance team and presented to leadership on a quarterly basis. All appropriate admitting staff will go through training to reinforce our slide process and review procedures for all FQHC services.
Finding 1205432 (2025-002)
Material Weakness 2025
Finding 2025-001 Name of contact person: Corrective Action: Proposed completion date: Finding 2025-002 Name of contact person: Corrective Action: Proposed completion date: Section IV - State Award Findings and Questioned Costs Corrective actions for Finding 2025-002 also apply to State Awards. Secti...
Finding 2025-001 Name of contact person: Corrective Action: Proposed completion date: Finding 2025-002 Name of contact person: Corrective Action: Proposed completion date: Section IV - State Award Findings and Questioned Costs Corrective actions for Finding 2025-002 also apply to State Awards. Section III - Federal Award Findings and Questioned Costs Corrective Action Plan Refresher training sessions will be fully completed for all Medicaid staff by the end of January 2026. Documentation standards and quality review processes are already in effect, with ongoing monitoring. Angel Carpenter and Goldie Davis - Medicaid Supervisors All Medicaid caseworkers will complete targeted refresher training on key eligibility and budgeting rules, including the use of online verification systems, accurate income and deduction calculations, household composition, recertification processes, and proper case documentation standards. Training will be delivered through a combination of state Learning Gateway courses, webinars, and internal sessions, with knowledge checks to confirm understanding. Staff will be reminded that “if it’s not documented, it didn’t happen.” Standardized documentation templates have been created and are now required for all cases to ensure thorough, clear, and consistent case notes. Second-party case reviews will continue and be expanded as needed to monitor ongoing accuracy. Case errors and lessons learned will be regular agenda items at monthly staff meetings, with emphasis on double-checking determinations before authorizing or releasing cases in NC FAST. Dedicated weekly time will be protected for staff to work pending verifications and system reports, with supervisory review. Section II - Financial Statement Findings 8/14/2025 Nikki Stanton, Finance Director The Nash County Finance Director was appointed effective April 14, 2025. Since that time, Finance has undertaken the following measures to strengthen operations and internal controls: • Reclassified job duties to better align responsibilities with organizational needs and improve efficiency. • Implemented additional internal controls to enhance the reliability and accuracy of financial processes. • Recruited and onboarded a dedicated Accountant to support the Accounting Manager. These changes have enabled the Accounting Manager to concentrate on performing timely reconciliations and preparing accurate journal entries, thereby improving the overall timeliness and quality of financial reporting. For the Year Ended June 30, 2025 Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 188
Cochise County Corrective Action Plan Year ended June 30, 2025 2025-101 Assistance Listings number and name: 10.557 WIC Special Supplemental Nutrition Program for Women, Infants, and Children Award number and years: CTR067930, October 1, 2023 through September 30, 2028 Federal agency: U.S. Departmen...
Cochise County Corrective Action Plan Year ended June 30, 2025 2025-101 Assistance Listings number and name: 10.557 WIC Special Supplemental Nutrition Program for Women, Infants, and Children Award number and years: CTR067930, October 1, 2023 through September 30, 2028 Federal agency: U.S. Department of Agriculture Pass-through grantor: Arizona Department of Health Services Compliance requirement: Eligibility Questioned costs: Unknown The County did not perform eligibility certification requirements, resulting in an increased risk of program participants receiving benefits they are not eligible to receive Contact: Barbara Lang Completion date: March 2026 Corrective Action: Cochise County WIC leadership and staff are committed to full adherence with WIC policy and will continue to implement training, monitoring, and communication to ensure compliance with federal and state regulation. This audit timeframe produced findings primarily related to issues that have already been corrected through the departure of staff that contributed to the findings (to include the previous Directors), hiring of new staff with a more thorough and comprehensive training plan implemented, and staff effort to retroactively collect all required signatures at subsequent appointments to ensure all WIC clients have current signatures and understanding of Rights & Obligations and Consents for their certification period. We recognize that these new processes were not put into plan until June 2025, due to the timing of the previous audit, and therefore did not reflect on the July 1, 2024 – June 30, 2025 audit period. In addition to the above resolved issues, a new WIC director was hired in September 2025 and new policies and procedures were immediately developed and put into place. These new policies and procedures that serve as our already implemented corrective action plan are as follows: Staff Training a. All staff are required to complete the full ADHS WIC-sponsored live cohort training courses upon hire, and every 3 years of their employment to ensure competencies are maintained over time. b. All staff complete their annual Civil Rights, Conflict of Interest, and Confidentiality upon hire and annually. Last annual training was completed Fall 2025. c. A staff dedicated as Training Coordinator monitors training logs and ensure all training requirements are met, with additional oversight by the WIC Director and the ADHS WIC State office. d. In-person staff meetings are held monthly, with a significant portion of time dedicated to staff training on programmatic expectations to ensure all staff obtain the same information so that tasks are carried out in a standardized method. e. Weekly team huddles to review any timely findings or discuss issues as a group. f. Weekly 1:1’s with each staff to discuss areas where the employee may need additional training or to discuss any deficiencies the WIC manager has noticed, (i.e. note-taking/documentation, single income verifications, chart review findings, etc.). Separation of Duties g. Cert List for Audits report run every 2 weeks for each clinic/staff person to review adherence to Separation of Duties. i. Follow up with certain percentage of clients per policy to assess how the certification went and verify client information. ii. Follow up with staff if any issues are identified. h. Staff have been training on during staff meetings in July 2025, August 2025, October 2025, and during new employee training on how to properly use the HANDS system to ensure the system accurately records who completed the 2nd income verification. i. Revision of Separation of Duties policy and implementation of new “protected time” procedure to ensure there is a staff person available at almost all times of day to complete the 2nd IV. *Since approval of this policy the ADHS WIC state office on 1/5/2026 and implementation of this policy/procedure, the Cert List for Audit report of single-income verifications has decreased substantially (from 60 in 2 weeks, to 5), all with documented reasons why 2nd IV was unable to be obtained during certification appointment and notes verifying 2nd IV was completed on another date. Rights and Obligations and Consent Forms a. All staff received a refresher training on 8/26/25, will be retrained annually, and are regularly reminded to obtain both required signatures at certification b. If staff are unable to obtain digital signatures due to tech issues, they are required to obtain e-document signatures via the clients email, or written signatures the staff then scans into the client file c. Chart reviews and staff observations are completed on a monthly-bimonthly basis to ensure ongoing staff compliance with policy and procedure
We have followed up with PaySchools and they have a target date of 4/30/26 for release of SOC Type II report, which should provide documentation on the effectiveness of their controls upon which we can rely when it comes to using their automated free and reduced application processing. In the meanti...
We have followed up with PaySchools and they have a target date of 4/30/26 for release of SOC Type II report, which should provide documentation on the effectiveness of their controls upon which we can rely when it comes to using their automated free and reduced application processing. In the meantime, our Food Service Supervisor will be reviewing all applications retroactive to the beginning of 2025-26.
2025-001 Material Weakness Internal Control / Noncompliance – Eligibility A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for maintaining supporting documentation to provide evidence of LCHD’s compliance with requirements applicable to each program funded under ...
2025-001 Material Weakness Internal Control / Noncompliance – Eligibility A. Comments on Findings and Recommendations: We concur with the auditor’s suggestions for maintaining supporting documentation to provide evidence of LCHD’s compliance with requirements applicable to each program funded under Uniform Guidance requirements. B. Actions Taken or Planned: Management implemented changes to the capturing and files maintained for documenting a participant’s eligibility for participation in program services. Management will continue to evaluate their controls with respect to current federal awards and requirements to ensure accurate information captured, reported and maintained. Anticipated completion date: Already implemented, ongoing Contact information for this finding: Michelle Walsh, 636-528-6117
Finding: 2025-2 Name of contact person: Amanda Murphy, Economic Programs Administrator Corrective Action: Corrections to the proper verifications, documentation or computation, income and policy findings have been completed. Supervisors have reviewed with individual staff the errors along with condu...
Finding: 2025-2 Name of contact person: Amanda Murphy, Economic Programs Administrator Corrective Action: Corrections to the proper verifications, documentation or computation, income and policy findings have been completed. Supervisors have reviewed with individual staff the errors along with conducting collective unit training on correct policy and keying procedures to ensure future accuracy. The Medicaid Supervisors. Lead Workers, and Quality Assurance team will continue to conduct monthly second party reviews as well as monthly policy/system training to improve quality in all areas. Proposed Completion Date: June 2026
Supporting Services for Veteran Families Program – Assistance Listing No. 64.033 Recommendation: The Organization should enhance the design and controls to ensure that an exit date cannot be assigned to a veteran unless proper due diligence is achieved in accordance with their policies and procedure...
Supporting Services for Veteran Families Program – Assistance Listing No. 64.033 Recommendation: The Organization should enhance the design and controls to ensure that an exit date cannot be assigned to a veteran unless proper due diligence is achieved in accordance with their policies and procedures Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Retraining of managers that exit approval does not happen till 3 documented attempts are in HMIS record. Name(s) of the contact person(s) responsible for corrective action: Eleni Clark Planned completion date for corrective action plan: 3/31/2026
Oversight Agency for Audit, Edward Romero Terrace respectfully submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit...
Oversight Agency for Audit, Edward Romero Terrace respectfully submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: October 1, 2024 through September 30, 2025 The finding from the September 30, 2025 schedule of findings and questioned costs is discussed below.The finding is numbered consistently with the number in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2025-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure that all required tenant eligibility steps are performed in accordance with HUD regulations and to ensure that all documentation related to tenants is properly executed and maintained. Action Taken: Staff training has been provided with additional HUD training inclusive of eligibility requirements and included in monthly reporting procedures. If the Oversight Agency for Audit has questions regarding the plan, please call Irene Phillips at 954-835- 9200. Sincerely yours, Irene Phillips CFO
Corrective Action Plan Eligibility Finding 2025-002 Roof Above will add signature lines to current client eligibility checklist, to include the name, signature and date for both the person preparing and the person reviewing tenant eligibility. Contact person responsible for corrective action: Katie ...
Corrective Action Plan Eligibility Finding 2025-002 Roof Above will add signature lines to current client eligibility checklist, to include the name, signature and date for both the person preparing and the person reviewing tenant eligibility. Contact person responsible for corrective action: Katie Church, Vice President of Scattered Site Housing Anticipated completion date: June 30, 2026
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