Corrective Action Plans

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The College implemented additional procedures to allow earlier detection of fraud.
The College implemented additional procedures to allow earlier detection of fraud.
FINDING 2025-003 Finding Subject: Title I Grants to Local Educational Agencies – Eligibility Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the f...
FINDING 2025-003 Finding Subject: Title I Grants to Local Educational Agencies – Eligibility Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Due to continued turnover in the Title I administrator position, application details have not been mastered. The treasurer and current Title I administrator are continuing to learn the process through guidance from our DOE Title I specialist and what we have learned from this audit. We will continue to work together on applying for future Title I grants and for the necessary implementation of the current Title I grant. Internal control over the processes will be developed and implemented, and will be notated with a “reviewed by” signature and date. Anticipated Completion Date: 2/16/2026
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Report training has been implemented and will continue on an ongoing basis to ensure compliance. We will implement periodic spot checks to prevent this issue from recurring and to ensure that all s...
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Report training has been implemented and will continue on an ongoing basis to ensure compliance. We will implement periodic spot checks to prevent this issue from recurring and to ensure that all students are properly enrolled each semester. Person Responsible for Corrective Action Plan: Registrar, Elena Majerowicz Anticipated Date of Completion: Already Implemented
Need Analysis Planned Corrective Action: System-generated notifications have been implemented within our student information system to flag any academic year changes or required reviews. In addition, a periodic review process of student award packages has been established to ensure funds are awarded...
Need Analysis Planned Corrective Action: System-generated notifications have been implemented within our student information system to flag any academic year changes or required reviews. In addition, a periodic review process of student award packages has been established to ensure funds are awarded accurately and in accordance with applicable awards. Person Responsible for Corrective Action Plan: Giselle Atenco, Director of Financial Aid Anticipated Date of Completion: Already Implemented
Eligibility Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.033, 84.268, 84.007 Recommendation: We recommend the University review its procedures to ensure that title IV funds is awarded correctly. Explanation of disagreement with audit finding: There is no disagreement with...
Eligibility Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.033, 84.268, 84.007 Recommendation: We recommend the University review its procedures to ensure that title IV funds is awarded correctly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Pell Grant awards are reviewed prior to each disbursement. SCU has strengthened this control to ensure award amounts are adjusted to accurately reflect each student’s enrollment intensity at the time of disbursement. This review is documented and completed by the Director of Financial Aid before funds are released to ensure compliance with federal requirements. Name(s) of the contact person(s) responsible for corrective action: Laney Morales, Director of Financial Aid Planned completion date for corrective action plan: 12/1/2025
Maywood-Melrose Park-Broadview School District 89 06-016-0890-02 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2025 Corrective Action Plan Finding No.: 2025- 003 Condition: It was noted during the audit that ineligible expenditures were charged to the food service expen...
Maywood-Melrose Park-Broadview School District 89 06-016-0890-02 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2025 Corrective Action Plan Finding No.: 2025- 003 Condition: It was noted during the audit that ineligible expenditures were charged to the food service expenditure function. These expenditures were for a back-to-school picnic and consisted of backpacks with school supplies that were provided to students, as well as a lunch provided to new teachers and staff. These expenditures should not have been charged to the food service function in the District’s general ledger system. Plan: The district is reviewing all expenditures monthly to ensure all of them are recorded with the proper account code. Any changes needed will get a journal entry through the Proviso Treasurer’s Office. The district has also identified the main vendors from which picnic supplies are purchased and stopped charging expenditures from these vendors to food service account codes. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Scott Wold, Business Manager
The County's current procedure requires documented acknowledgement that the vendor was verfied to not be suspended, debarred, or otherwise excluded prior to entering covered transactions. Effective February 25, 2026, the County's procedure will require documented verfication that vendors are not sus...
The County's current procedure requires documented acknowledgement that the vendor was verfied to not be suspended, debarred, or otherwise excluded prior to entering covered transactions. Effective February 25, 2026, the County's procedure will require documented verfication that vendors are not suspended, debarred, or otherwise excluded prior to entering into covered transactions and retain such documnetation within the procurement file, in accordance with CFR 200.212 and 200.318(h), 2 CFR 180.300, and 48 CFR 52.209-6.
Corrective Action Plan Finding No. 2025-001 – Eligibility (Federal Work Study Program) Federal Program: Student Financial Assistance Cluster – Federal Work Study (ALN 84.033) Federal Agency: U.S. Department of Education Audit Period: July 1, 2024 – June 30, 2025 Finding Summary During testing of stu...
Corrective Action Plan Finding No. 2025-001 – Eligibility (Federal Work Study Program) Federal Program: Student Financial Assistance Cluster – Federal Work Study (ALN 84.033) Federal Agency: U.S. Department of Education Audit Period: July 1, 2024 – June 30, 2025 Finding Summary During testing of student eligibility, auditors identified one instance in which a student’s Cost of Attendance (COA) was increased by $2,810 due to participation in the Federal Work Study (FWS) program. Federal regulations do not permit an institution to increase COA solely to accommodate FWS eligibility. Although the adjustment did not result in the student receiving aid exceeding financial need, the adjustment occurred due to a misunderstanding of guidance related to the FWS program. Corrective Action Plan Management agrees with the finding. To address the finding and ensure compliance with federal regulations governing the Federal Work Study program, the Office of Financial Aid will implement the following corrective actions: 1. Policy Clarification and Documentation The Office of Financial Aid will revise its internal awarding policies and procedures to clearly state that the standard practice of awarding Federal Work Study funds must fit within the student established Cost of Attendance (COA). Additionally, the revised policy will explicitly include flexibility to increase the Cost of Attendance only because of approved Special Circumstance appeals, consistent with federal guidance and institutional professional judgment policies. Federal Student Aid Handbook: Application and Verification Guide: Chapter 5 – Special Cases 2. Award Adjustment Procedures When a student’s aid package exceeds need due to the addition of FWS, staff will take the following steps: • Reduction of loan awards, when applicable, to allow FWS funding to be added within the student’s financial need limits.A Loan Adjustment Form will be required for all downward adjustments to loan awards to ensure documentation and transparency. These procedures will ensure that aid adjustments remain compliant with federal need-analysis requirements. Implementation Timeline • Policy updates and procedural documentation: Within 60 days • Process implementation: Beginning with the 2026-2027 academic year packaging cycle
Responsible Person(s): Kavansa Gardner, Business Program Manager Senior, Benefit Programs; David Carico, Business Operations Manager Corrective Action Planned: Below is the narrative for CR901 and CR902 Records Retention, including current production deployment timelines. CR901 establishes the datab...
Responsible Person(s): Kavansa Gardner, Business Program Manager Senior, Benefit Programs; David Carico, Business Operations Manager Corrective Action Planned: Below is the narrative for CR901 and CR902 Records Retention, including current production deployment timelines. CR901 establishes the database infrastructure required to support compliant records retention within case management system. This includes partition creation across 75 plus high volume tables to enable structured aging and controlled purge activity aligned to retention thresholds. Production Deployment Timeline; scheduled as part of the February 2026 technical release. This phase is foundational and will be completed before purge logic can safely execute. CR902 Retention Logic and controlled execution; CR902 operationalizes the records retention policy by implementing controlled purge jobs leveraging the partitioning framework established in CR901. This Change Request moves the solution from infrastructure readiness to active lifecycle management. Phase 1 Database partition creation (February 2026 production release schedule) Phase 2 Controlled purge implementation (March 2026 release schedule) Phase 3 Validation, audit confirmation, and reporting controls (April 2026 release schedule) Phase 4 Reoccurring operational retention cycles with documented runbooks (ongoing/living) Estimated Completion Date: 4/30/2026
Responsible Person(s): Kavansa Gardner, Business Program Manager Senior, Benefit Programs; Lunita Browder-Harris, Business Operation Specialist, Business Operations Corrective Action Planned: DSS has identified critical or conflicting roles in the management system. The roles in scope have the capab...
Responsible Person(s): Kavansa Gardner, Business Program Manager Senior, Benefit Programs; Lunita Browder-Harris, Business Operation Specialist, Business Operations Corrective Action Planned: DSS has identified critical or conflicting roles in the management system. The roles in scope have the capability to perform all actions within the system, including inputting applications, determining eligibility, and authorizing benefits. DSS is in the process of implementing a procedure for reviewing and revoking conflicting roles ands privileges for all localities. DSS will work with APA to ensure adequate separation of duties is implemented within the eligibility system. Estimated Completion Date: 6/30/2026
Responsible Person(s): Meredith Lumpkin/J’Noie Parker, Child Care Subsidy Program Manager Corrective Action Planned: 1.) Process Redesign and Standardization: DSS has redefined the redetermination packet to require submission of the application and all required verifications to ensure complete docum...
Responsible Person(s): Meredith Lumpkin/J’Noie Parker, Child Care Subsidy Program Manager Corrective Action Planned: 1.) Process Redesign and Standardization: DSS has redefined the redetermination packet to require submission of the application and all required verifications to ensure complete documentation to streamline eligibility review. Updated procedural guidance has been incorporated into the Interim Guidance Manual to clarify verification requirements and documentation standards. A standardized step-by-step resource guide and redetermination flow chart have been developed outlining required actions, decision points, and the importance of reviewing redetermination monitoring reports on a monthly basis to ensure cases do not exceed eligibility periods. 2.) Immediate Remediation: In January, following the initial APA audit, DSS conducted a statewide scope and scale review of all active cases to identify outstanding redeterminations. Through this analysis, DSS identified 88 overdue redeterminations (31 from January 2026 and 57 from periods prior to January 2026). Local departments and appropriate staff were notified individually of the specific cases requiring action and directed to take corrective steps. DSS will review cases at the end of March to ensure action has been taken. Going forward, DSS will direct all local departments to review the monthly system-generated redetermination monitoring report and resolve any cases identified as exceeding the eligibility period. DSS will distribute targeted overdue case lists to Regional Program Consultants (RPCs) and monitor locality progress through centralized tracking to ensure timely eligibility determinations and ongoing CCDF compliance. 3.) Centralized Oversight: DSS will implement a layered oversight process to ensure compliance with required monthly monitoring procedures: -Regional-Level Review: Regional Program Consultants (RPCs) will review redetermination monitoring activity monthly within their assigned localities and direct corrective action as needed to ensure timely processing and case closure when appropriate. -Home Office Verification: DSS Home Office, in collaboration with DOE, will conduct quarterly reviews of regional monitoring activity to verify compliance and provide direction to RPCs where additional corrective action or technical assistance is required. This dual-level oversight structure establishes both ongoing regional monitoring and periodic centralized verification to reduce the risk of recurrence. 4.) Training: Refresher training will be provided to staff at our Benefits Program Conference in April, emphasizing timely processing, required verifications, system documentation standards, and ongoing monitoring responsibilities. Additionally, DSS is collaborating with the Local Training and Development team to initiate the development of a targeted refresher course for tenured staff to reinforce critical requirements, including the redetermination process. Monthly report review, as outlined in bullet two, will inform ongoing training updates to address. 5.) System Control Evaluation: DSS will collaborate with IT to assess potential system enhancements in future releases to strengthen controls related to redetermination due dates, including additional automated functionality or reporting capabilities. DSS will deliver to CCSP leadership, by June 30, 2026, a prioritized list of recommended system enhancements with associated cost estimates for review and consideration. Estimated Completion Date: 6/30/2026
Responsible Person(s): Office of Information Management and Othello Dixon, Office of Information Security Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 ...
Responsible Person(s): Office of Information Management and Othello Dixon, Office of Information Security Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 3/2/2026
Finding 2025-002 - Significant Deficiency in Internal Control over Compliance - Student Financial Condition Found: One undergraduate student had aggregate subsidized loans over the aggregate limit. Corrective Action Plan: Previously, Antioch College utilized loan history data from Free Application f...
Finding 2025-002 - Significant Deficiency in Internal Control over Compliance - Student Financial Condition Found: One undergraduate student had aggregate subsidized loans over the aggregate limit. Corrective Action Plan: Previously, Antioch College utilized loan history data from Free Application for Federal Student Aid (FAFSA). FAFSA data was utilized because National Student Loan Data System (NSLDS) loan history data was not always available when Antioch College prepared financial aid award letters. Due to the potential loan history discrepancies between data reported via FAFSA versus NSLDS, at the start of each academic year, Antioch College now uses NSLDS data to update loan history of each student to ensure Antioch College has the correct loan balances for each student. This procedural change was put into effect with the start of the 2025-2026 academic year. Person Responsible for Corrective Action Plan Implementation: Director of Financial Aid
2025-002: Lack of Operating Effectiveness on Internal Control Over Compliance for Distributions of Food Commodities Corrective Action Plan: Established three checks and balances that are currently in practice: I. Invoices are reviewed by Senior Transportation Manager to ensure signed. 2. Once review...
2025-002: Lack of Operating Effectiveness on Internal Control Over Compliance for Distributions of Food Commodities Corrective Action Plan: Established three checks and balances that are currently in practice: I. Invoices are reviewed by Senior Transportation Manager to ensure signed. 2. Once reviewed by Senior Transportation Manager, invoice is handed off to Partner Services Representative for verification of signatures and electronically scanned into centralized database. 3. Director of Operations reviews all invoices for completion. of signature in database on a weekly basis. Director of Operations uses a control sheet to check against CERES ERP system. Managements Plan: We will continue to monitor and identify any gaps in the CAP outlined above to ensure compliance with appropriate signatures is met. Name of Responsib le Person: Meredith Knopp, Chief Executive Officer Anticipated Completion Date: Implemented effective October 31, 2025
Section III – Federal Award Finding and Questioned Costs Finding 2025-002 – Eligibility Federal Program: Child and Adult Care Food Program (ALN 10.558) Views of Responsible Officials: NDS management met with CACFP staff to review procedures intended to enhance oversight of student eligibility determ...
Section III – Federal Award Finding and Questioned Costs Finding 2025-002 – Eligibility Federal Program: Child and Adult Care Food Program (ALN 10.558) Views of Responsible Officials: NDS management met with CACFP staff to review procedures intended to enhance oversight of student eligibility determinations on February 10, 2026. The Assistant Administrator for the Child and Adult Care Food Program, Ms. Dawn McCoy, (dmccoy@ndsarch.org) will be responsible for ensuring adherence to these updated procedures.
2025-004 (2024-004) Special Tests and Provisions: Provider Eligibility (Significant Deficiency in Internal Controls over Compliance) What Action(s) Will be Done: Re-implementation of the recertification and revalidation processes is currently completed in the provider enrollment system. We are movin...
2025-004 (2024-004) Special Tests and Provisions: Provider Eligibility (Significant Deficiency in Internal Controls over Compliance) What Action(s) Will be Done: Re-implementation of the recertification and revalidation processes is currently completed in the provider enrollment system. We are moving forward with the revalidation/recertification implementation. Initial provider notifications (90-day notice) will be issued in March 2026. Who Will Act: Bureau Chief, Provider Enrollment Services Bureau, Medical Assistance Division When Will Action(s) be Completed: Corrective actions are expected to be implemented by June 30, 2026.
Corrective Action Plan: Catholic Charities Program Manager conducted the CACFP annual staff training on 12/17/2025 with all CACFP staff present. The annual audit was discussed. Each staff member will review all claims for accuracy before entering the claim into the State's online website for reimbur...
Corrective Action Plan: Catholic Charities Program Manager conducted the CACFP annual staff training on 12/17/2025 with all CACFP staff present. The annual audit was discussed. Each staff member will review all claims for accuracy before entering the claim into the State's online website for reimbursement. Program Manager, Joanne Varnes, will conduct case record reviews of the providers’ files/claims to ensure participants are reimbursed at the correct rate, days, and number of meals served. Contact Person Responsible for Corrective Action: Joanne Varnes, CACFP Program Manager Anticipated Completion Date of Corrective Action: December 17, 2025
Eligibility for a resident was not supported. Recommendation: CLA recommends enforcing control procedures over resident eligibility. Explanation of disagreement with audit finding: Management identifies that the resident move-in was conducted by the prior management company. Action planned in respon...
Eligibility for a resident was not supported. Recommendation: CLA recommends enforcing control procedures over resident eligibility. Explanation of disagreement with audit finding: Management identifies that the resident move-in was conducted by the prior management company. Action planned in response to finding: During fiscal 2026, the management company will recommunicate their policies and ensure proper controls over eligibility are enforced. Name of the contact person responsible for corrective action: Sabine Cox, EHM Comptroller Planned completion date for corrective action plan: September 30, 2026
An ineligible resident was residing at the property. Recommendation: CLA recommends enforcing control procedures over resident eligibility. Explanation of disagreement with audit finding: Management identifies that the resident move-in was conducted by the prior management company. Action planned in...
An ineligible resident was residing at the property. Recommendation: CLA recommends enforcing control procedures over resident eligibility. Explanation of disagreement with audit finding: Management identifies that the resident move-in was conducted by the prior management company. Action planned in response to finding: During fiscal 2026, the management company will recommunicate their policies and ensure proper controls over eligibility are enforced. Name of the contact person responsible for corrective action: Sabine Cox, EHM Comptroller Planned completion date for corrective action plan: September 30, 2026
The Department will complete and communicate formalized IT procedures to staff and IT service providers for IT general control activities for MyUI+ by April 2026.
The Department will complete and communicate formalized IT procedures to staff and IT service providers for IT general control activities for MyUI+ by April 2026.
The Department will implement Part B of the confidential finding.
The Department will implement Part B of the confidential finding.
The Department agrees to strengthen its internal controls over Medicaid eligibility to ensure compliance with federal and state regulations. Colorado will continue its approved Centers for Medicare and Medicaid mitigation plan to ensure that eligibility is determined on an individual rather than a h...
The Department agrees to strengthen its internal controls over Medicaid eligibility to ensure compliance with federal and state regulations. Colorado will continue its approved Centers for Medicare and Medicaid mitigation plan to ensure that eligibility is determined on an individual rather than a household basis. The Department will continue to conduct ex parte reviews to determine eligibility for all household members based on available information. Those members identified as eligible at ex parte will be approved, regardless if others in the household continue to need verifications or are no longer eligible. The Department is currently working on a permanent system change for CBMS that will only send out renewal forms for individuals not eligible through the ex parte process, with implementation by December 2026.
The Department agrees with the recommendation and will strengthen internal controls over Children’s Basic Health Plan eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring ...
The Department agrees with the recommendation and will strengthen internal controls over Children’s Basic Health Plan eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring Department-approved Corrective Action Plans. These plans will be required to address root causes related to income documentation, application of correct income thresholds, and compliance with CBHP eligibility requirements, including any necessary training or guidance for county and Medical Assistance site caseworkers. The Department will review, approve, and monitor corrective actions to ensure deficiencies are addressed.
The Department agrees with the recommendation and will strengthen internal controls over Medicaid eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring the development and ...
The Department agrees with the recommendation and will strengthen internal controls over Medicaid eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring the development and implementation of Department-approved Corrective Action Plans. These plans will be required to address root causes related to income and resource calculation, documentation of eligibility determinations, and household composition, including any necessary training or guidance for county and Medical Assistance site caseworkers. The Department will review, approve, and monitor corrective actions to ensure deficiencies are appropriately addressed.
Re: Finding 2025 001 – Significant Deficiency in Internal Control Over Financial Reporting – Preparation of the Schedule of Expenditures of Federal Awards (SEFA) The Corporation agrees with the recommendation. Management acknowledges that certain federal expenditures were not initially reported on t...
Re: Finding 2025 001 – Significant Deficiency in Internal Control Over Financial Reporting – Preparation of the Schedule of Expenditures of Federal Awards (SEFA) The Corporation agrees with the recommendation. Management acknowledges that certain federal expenditures were not initially reported on the Schedule of Expenditures of Federal Awards (SEFA) in the appropriate fiscal periods due to a misunderstanding of applicable Uniform Guidance requirements and reliance on prior audit treatment. Specifically, expenditures related to Federal Emergency Management Agency (FEMA) programs were not included on the SEFA until reimbursement was received, and certain per patient payments associated with federally funded research were not initially identified as SEFA reportable. To address this matter and strengthen internal controls over the preparation and review of the SEFA, management will implement the following corrective actions: • Future FEMA expenditures will be reported on the SEFA in the fiscal year in which the projects are obligated and eligible expenditures are incurred, regardless of the timing of reimbursement. • Per patient payments received in connection with federally funded research programs will be evaluated for SEFA reporting and included as required. • A formal Standard Operating Procedures related to the preparation of the SEFA will be developed and implemented to clarify reporting requirements for obligated expenditures, per patient grant activity, and other federal awards. • Review procedures will be enhanced to include confirmation by entity and corporate leadership that all federal awards and related expenditures have been identified, evaluated, and appropriately reported on the SEFA. • Management will evaluate opportunities to complete SEFA preparation and preliminary review earlier in the audit cycle to allow for timely identification and resolution of potential reporting issues. Management believes these actions will improve the accuracy and completeness of the SEFA and reduce the risk of similar issues in future reporting periods.
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