Corrective Action Plans

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Finding: 2024-004 Material Weakness in Internal Control Over Special Tests – Health Center Program (93.224) Corrective Action: We will develop a checklist for patient discount documentation and implement a control requiring supervisor approval for overrides. We will also perform monthly file audits ...
Finding: 2024-004 Material Weakness in Internal Control Over Special Tests – Health Center Program (93.224) Corrective Action: We will develop a checklist for patient discount documentation and implement a control requiring supervisor approval for overrides. We will also perform monthly file audits and report exceptions to the appropriate personnel. Proposed Completion Date: February 28, 2026 Name of Contact Person: Lane Baker, CHW Chief Operating Officer
2024-005 Material Weakness in Internal Control over Compliance 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: During our testing of participant eligibility, we selected a sample of 40 participants receiving me...
2024-005 Material Weakness in Internal Control over Compliance 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: During our testing of participant eligibility, we selected a sample of 40 participants receiving meals at centers contracted with the CBS Food Program. For 2 of the 40 participants, management was unable to provide complete and valid eligibility documentation. In one instance, the only available eligibility form had been prepared in a future fiscal year, and in another instance, the eligibility form could not be located at all. Recommendation: We recommend that management strengthen its CACFP eligibility documentation procedures to ensure that all required forms are properly completed, collected, and retained for every participant. This should include implementing a standardized intake process, maintaining timely reviews to confirm completeness of eligibility files, and developing a tracking or monitoring system to identify missing or outdated documentation. Management should also reinforce internal expectations for timely updating of eligibility files and ensure staff are trained on CACFP documentation requirements. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: On February 1, 2025, Community Benefit Solutions rolled out the KidKare software system wide. KidKare is a CACFP software that allows Community Benefit Solutions to digitally process all eligibility-documentation, standardize the enrollment procedures, ensure forms are completed in accordance with the relevant regulations, request updated documentation upon the expiration of enrollment forms, and digitally store all the eligibility related information for all participants. Planned completion date for corrective action plan: June 30, 2025
Concord’s Compliance Dept has implemented procedures to ensure the tenant security deposits are correctly recorded, tenant eligibility is correctly determined and that the tenant lease files are properly maintained in accordance with HUD’s requirements.
Concord’s Compliance Dept has implemented procedures to ensure the tenant security deposits are correctly recorded, tenant eligibility is correctly determined and that the tenant lease files are properly maintained in accordance with HUD’s requirements.
The District acknowledges that the fiscal year 2024 Single Audit was not completed within the nine-month deadline. Fiscal year 2024 was the District’s first year meeting the expenditure threshold requiring a Single Audit, and staff were not previously aware that the Single Audit shared the same nine...
The District acknowledges that the fiscal year 2024 Single Audit was not completed within the nine-month deadline. Fiscal year 2024 was the District’s first year meeting the expenditure threshold requiring a Single Audit, and staff were not previously aware that the Single Audit shared the same nine-month reporting requirement as the annual financial statement audit. The District is implementing procedures to prevent recurrence, including obtaining additional training on Single Audit requirements and updating internal reporting calendars to ensure timely completion in future years. The District is committed to compliance with all federal and state reporting requirements moving forward.
Management Response The owner/manager of the building, St. Philip the Evangelist Episcopal Church, occupied by St. Philip’s Child Development Center (the Center) declared bankruptcy and ceased operating in November 2024. Maintenance on building systems and its structures had been deferred for severa...
Management Response The owner/manager of the building, St. Philip the Evangelist Episcopal Church, occupied by St. Philip’s Child Development Center (the Center) declared bankruptcy and ceased operating in November 2024. Maintenance on building systems and its structures had been deferred for several years. On July 27, 2025, the building experienced a roof leak causing a catastrophic flood. The building was evacuated and the Office of State Superintendent (OSSE) notified. OSSE sent an inspector to the site the following day who declared the building unsafe for occupancy. The Church was unable to cover any costs for the necessary repairs. On July 30, 2025 the Board of Directors made the difficult decision to suspend operations, but to continue as a Board, maintain the Center’s 501(c)3 status and its corporate registration. Furthermore, the Board is using this time to research current community needs, space availability and cost, and the effect of the Federal government’s waning support for early childhood education. Once this exercise is complete, the Board will determine the Center’s ability to reopen in an alternate site and address the findings in an appropriate manner.
Review individual grants for eligibility and documentation requirements • Create a policy to review the application for eligibility and ensure second approval on each application • Retain all documentation required by the grants
Review individual grants for eligibility and documentation requirements • Create a policy to review the application for eligibility and ensure second approval on each application • Retain all documentation required by the grants
FINDING 2024-013 Finding Subject: Title I Grants to Local Educational Agencies - Eligibility Contact Person Responsible for Corrective Action: Tricia Hudson, Curriculum Director & Federal Grants Administrator Contact Phone Number and Email Address: 812.279.3521, ext. 16242; hudsont@nlcs.k12.in.us Vi...
FINDING 2024-013 Finding Subject: Title I Grants to Local Educational Agencies - Eligibility Contact Person Responsible for Corrective Action: Tricia Hudson, Curriculum Director & Federal Grants Administrator Contact Phone Number and Email Address: 812.279.3521, ext. 16242; hudsont@nlcs.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The school district will maintain documentation of the nonpublic schools’ rosters with supporting poverty documentation in the form of free and reduced meal applications saved on file with the Title I application annually. Anticipated Completion Date: The school district began the practice above for the 2023-24 school year. The school district has supporting documentation of free and reduced lunch status for nonpublic school students for the 2023-24 school year and moving forward. This corrective action will be fully completed by June 30, 2026.
Federal Agency: US Department of Education Federal Program Name: Federal Perkins Loan Program Assistance Listing No.: 84.038 Recommendation: We recommend reviewing procedures around Perkins Loan Program funds and implementing reconciliations and review to the third-party servicer reports. Explanatio...
Federal Agency: US Department of Education Federal Program Name: Federal Perkins Loan Program Assistance Listing No.: 84.038 Recommendation: We recommend reviewing procedures around Perkins Loan Program funds and implementing reconciliations and review to the third-party servicer reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The university has implemented policies and procedures regarding reconciliations for Perkins loan services managed by a 3rd party supplier. Name(s) of the contact person(s) responsible for corrective action: Danyel Tolbert, Bursar Planned completion date for corrective action plan: Complete
Federal Agency: US Department of Education Federal Program Name: Federal Perkins Loan Program Assistance Listing No.: 84.038 Recommendation: We recommend reviewing procedures and requirements regarding Perkins third-party service providers to ensure compliance with regulations. Explanation of disagr...
Federal Agency: US Department of Education Federal Program Name: Federal Perkins Loan Program Assistance Listing No.: 84.038 Recommendation: We recommend reviewing procedures and requirements regarding Perkins third-party service providers to ensure compliance with regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The university has implemented policies and procedures regarding reconciliations for Perkins loan services managed by a 3rd party supplier. Name(s) of the contact person(s) responsible for corrective action: Danyel Tolbert, Bursar Planned completion date for corrective action plan: Complete
2024-005 – Insufficient Financial Management Finding: Our audit procedures disclosed that the Organization drew down more revenues than expenditures incurred. Recommendation: We recommend that Homeward Bound Adirondack, Inc. establish oversight practices to ensure that all revenues and expenses are ...
2024-005 – Insufficient Financial Management Finding: Our audit procedures disclosed that the Organization drew down more revenues than expenditures incurred. Recommendation: We recommend that Homeward Bound Adirondack, Inc. establish oversight practices to ensure that all revenues and expenses are recorded appropriately and reconciled to the proper drawdown requests Action Taken: We are creating a policy and procedure to include the bookkeeper submitting the weekly expenses to the Executive Director for review and sign off prior to executing the draw downs to ensure proper allocation of costs. The Executive Director has contacted the Fox grants team concerning this matter.
2024-003 – Ineligible Program Participants Finding: Our audit procedures disclosed that several program participants were determined ineligible based on missing documentation of participants being a veteran or having qualifying military service. Recommendation: We recommend that Homeward Bound Adiro...
2024-003 – Ineligible Program Participants Finding: Our audit procedures disclosed that several program participants were determined ineligible based on missing documentation of participants being a veteran or having qualifying military service. Recommendation: We recommend that Homeward Bound Adirondack, Inc. implement an eligibility checklist to ensure all required eligibility documentation is complete and accurate prior to approving payments. We also recommend Homeward Bound Adirondack, Inc. provide appropriate training to staff on documentation of eligibility requirements and that their training be documented for each staff. Action Taken: Policies have been developed and were reviewed at mandatory staff training on 10/29/25
Finding # 2024-002: Significant deficiency over eligibility U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: Applications to the program should be reviewed and approved prior to acceptance into the program. One application out of 40 tested had the same person...
Finding # 2024-002: Significant deficiency over eligibility U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: Applications to the program should be reviewed and approved prior to acceptance into the program. One application out of 40 tested had the same person doing initial and secondary review. Recommendation: Applications should consistently have advisors or college prep specialists sign off and review prior to the program manager doing secondary review and acceptance. Corrective Action: Management adopted a policy requiring separate reviews effective April 2024. The exception noted occurred before the new policy was implemented. We will have the Executive Director and College+ Program Manager ensure that all advisors review applications before sending to the College+ Program Manager for approval and acceptance. Anticipated Completion Date: April 2025
Supporting Documentation for Family Size Allowable Costs, Eligibility – Housing Choice Vouchers – CFDA No. 14.871 Recommendation: Management should create an internal monitoring system to ensure that tenant files are scanned/saved appropriately, and the documentation meets all program guidelines. Ex...
Supporting Documentation for Family Size Allowable Costs, Eligibility – Housing Choice Vouchers – CFDA No. 14.871 Recommendation: Management should create an internal monitoring system to ensure that tenant files are scanned/saved appropriately, and the documentation meets all program guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is reviewing work completed by the Housing Specialists more frequently, by performing more Quality Control evaluations, reviewing software-flagged errors, and establishing more check-ins with staff who are producing frequent errors. If frequent errors persist after consistent coaching, Corrective Action Plans will be put in place for those staff members. Termination of employees unable to produce accurate work will be enforced if coaching and Corrective Action Plans prove unsuccessful. Names of the contact persons responsible for corrective action: April Clark and Nicole Thompson Planned completion date for corrective action plan: Currently Implemented & Ongoing
Calculating Expenses for Family Income Examinations Allowable Costs, Eligibility – Housing Choice Vouchers – CFDA No. 14.871 Recommendation: Management should review their current processes and create an internal monitoring system to ensure the expenses are appropriately calculated in the future and...
Calculating Expenses for Family Income Examinations Allowable Costs, Eligibility – Housing Choice Vouchers – CFDA No. 14.871 Recommendation: Management should review their current processes and create an internal monitoring system to ensure the expenses are appropriately calculated in the future and/or consider additional training for housing specialists to ensure HAP is appropriately calculated. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is reviewing work completed by the Housing Specialists more frequently, by performing more Quality Control evaluations, reviewing software-flagged errors, and establishing more check-ins with staff who are producing frequent errors. If frequent errors persist after consistent coaching, Corrective Action Plans will be put in place for those staff members. Termination of employees unable to produce accurate work will be enforced if coaching and Corrective Action Plans prove unsuccessful. Names of the contact persons responsible for corrective action: April Clark and Nicole Thompson Planned completion date for corrective action plan: Currently Implemented & Ongoing
Calculating Income / Retaining Supporting Documentation for Family Income Examinations Allowable Costs, Eligibility – Housing Choice Vouchers – CFDA No. 14.871 Recommendation: Management should create an internal monitoring system to ensure that tenant files are scanned/saved appropriately, and the ...
Calculating Income / Retaining Supporting Documentation for Family Income Examinations Allowable Costs, Eligibility – Housing Choice Vouchers – CFDA No. 14.871 Recommendation: Management should create an internal monitoring system to ensure that tenant files are scanned/saved appropriately, and the documentation meets all program guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is reviewing work completed by the Housing Specialists more frequently, by performing more Quality Control evaluations, reviewing software-flagged errors, and establishing more check-ins with staff who are producing frequent errors. If frequent errors persist after consistent coaching, Corrective Action Plans will be put in place for those staff members. Termination of employees unable to produce accurate work will be enforced if coaching and Corrective Action Plans prove unsuccessful. Names of the contact persons responsible for corrective action: April Clark and Nicole Thompson Planned completion date for corrective action plan: Currently Implemented & Ongoing
Missing Tenant Files Allowable Costs, Eligibility – Housing Choice Vouchers – CFDA No. 14.871 Recommendation: Management should review their current processes and create an internal monitoring system to ensure appropriate forms and supporting documentation are in the file in the future and/or consid...
Missing Tenant Files Allowable Costs, Eligibility – Housing Choice Vouchers – CFDA No. 14.871 Recommendation: Management should review their current processes and create an internal monitoring system to ensure appropriate forms and supporting documentation are in the file in the future and/or consider additional training for housing specialists to ensure tenant files are retained and scanned into the online system in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement that part of the document retention process is to not only upload the documents, but then verify within the tenant file that documents are present and fully legible. Names of the contact persons responsible for corrective action: April Clark and Nicole Thompson Planned completion date for corrective action plan: November 1, 2025
Federal Agency: U.S. Department of Agriculture Federal Program Name: Supplemental Nutrition Assistance Program Cluster Assistance Listing Number: 10.561 Federal Award Identification Number and Year: 242MN101S2514 – 2024 Passed Through Entity: Minnesota Department of Human Services Pass Through Numbe...
Federal Agency: U.S. Department of Agriculture Federal Program Name: Supplemental Nutrition Assistance Program Cluster Assistance Listing Number: 10.561 Federal Award Identification Number and Year: 242MN101S2514 – 2024 Passed Through Entity: Minnesota Department of Human Services Pass Through Number: H55240010 Award Period: 2024 Recommendation: We recommend the County implement process and procedures to provide reasonable assurance that all necessary documentation to support eligibility determination exists and is properly input or updated in MAXIS and issues are followed up in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will continue to train staff to ensure they are aware that review of casefiles needs to be documented by a signature for all applications, all information in casefiles needs to be accurately input into MAXIS for income and assets, and all applications should be processed in a timely and accurate manner. Name of the contact person responsible for corrective action: Tiffinie Miller, Deputy Director of Employment & Economic Assistance Planned completion date for corrective action plan: December 31, 2025
Views of Auditee and Corrective Actions: GDOE agrees with the finding. Plan of action and completion date: The Food and Nutrition Services Management Division (FNSMD) will implement an internal calendar reminder to ensure timely notification to School Districts and the annual upload of district-wide...
Views of Auditee and Corrective Actions: GDOE agrees with the finding. Plan of action and completion date: The Food and Nutrition Services Management Division (FNSMD) will implement an internal calendar reminder to ensure timely notification to School Districts and the annual upload of district-wide eligibility information for the Community Eligibility Provision (CEP) to the FNSMD and GDOE websites. Additionally, FNSMD will implement an internal process to conduct the Direct Certification Matching activity to determine student eligibility for free school meals (Lunch/Breakfast). This process will include matching student data with lists from the Department of Public Health & Social Services (DPHSS) for SNAP (Food Stamps), TANF, FDPIR, Medicaid, Foster Care, Homelessness, or Migrant status. All Direct Certification Matching activities will be completed by April 1st of each year. Plan to monitor and responsible officials: The FNSMD Administrator, Anthony S. Monforte, and FNSMD Program Coordinator, Franklin J. Cruz, will be responsible for implementation and ongoing execution of corrective actions. Corrective actions will be implemented by March 31, 2026.
The findings have been resolved as of 4/2/2025. A $21,073 deposit was made to the residual receipt bank account on this date.
The findings have been resolved as of 4/2/2025. A $21,073 deposit was made to the residual receipt bank account on this date.
Recommendation: We recommend the City establish procedures to ensure that the review and approval processes are clearly documented within each tenant file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The RBHA w...
Recommendation: We recommend the City establish procedures to ensure that the review and approval processes are clearly documented within each tenant file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The RBHA will establish procedures to monitor and ensure proper file review. RBHA has created a new checklist for a supervising team member to review intake files for accuracy, to document approval, and to release the Housing Assistance Payment. RBHA will maintain records of the signed checklist for each tenant file. Name of the contact person responsible for corrective action: Imelda Delgado, Housing Manager Planned completion date for corrective action plan: January 2026.
Effective immediately, Berne Union will require PaySchools to provide its policies and procedures governing the eligibility determination process for free, reduced, and paid meal status. These documents will be reviewed to ensure compliance with federal standards for the Free and Reduced-Price Lunch...
Effective immediately, Berne Union will require PaySchools to provide its policies and procedures governing the eligibility determination process for free, reduced, and paid meal status. These documents will be reviewed to ensure compliance with federal standards for the Free and Reduced-Price Lunch Program.
Oversight Agency for Audit Tri-County Housing, Inc. dba Total Concept & Subsidiaries respectfully submits the following corrective action plan for the year ended December 31, 2024. Name of independent accounting firm: Audit Period: January 1, 2024 through December 31, 2024. The finding from the Dece...
Oversight Agency for Audit Tri-County Housing, Inc. dba Total Concept & Subsidiaries respectfully submits the following corrective action plan for the year ended December 31, 2024. Name of independent accounting firm: Audit Period: January 1, 2024 through December 31, 2024. The finding from the December 31, 2024 Schedule of Findings and Questioned Costs is discussed below. Finding 2024-1 Comments of the finding and recommendation: Management agrees with the finding. Action taken: We will assign the Executive Director to oversee all federal reporting deadlines and implement a centralized compliance calendar with automated reminders. Internal policies will be updated to require a formal review of reporting documents at least 45 days prior to submission deadlines. Additionally, relevant staff will receive training on Uniform Guidance requirements, and quarterly compliance meetings will be held to monitor progress. These actions are intended to ensure timely and accurate future submissions in accordance with federal regulations. If the oversight agency has questions regarding this plan, please email Steven Cordova, executive director of Tri-County Housing, Inc. dba Total Concept & Subsidiaries at scordova@totalconcept.net. Sincerely yours, Tri-County Housing, Inc. dba Total Concept & Subsidiaries
Community Health Center in Cowley County, Inc. acknowledges the repeat finding regarding application of sliding fee discounts. To address this, we have: • Continued weekly meetings between frontline staff and the billing/revenue department to reinforce policy alignment. • Enhanced and formalized tra...
Community Health Center in Cowley County, Inc. acknowledges the repeat finding regarding application of sliding fee discounts. To address this, we have: • Continued weekly meetings between frontline staff and the billing/revenue department to reinforce policy alignment. • Enhanced and formalized training programs for all staff involved in eligibility screening and discount application. • Updated our Financial and Sliding Fee policies to clarify procedures and eligibility criteria. These actions are part of our ongoing commitment to improving internal controls and ensuring compliance with federal program requirements. Effectiveness will be monitored through periodic audits and staff feedback.
Finding 2024-002 Federal Agency U.S. Department of Housing and Urban Development Federal Program Community Project Funding Compliance Requirements E - Eligibility Finding Type Federal Awards Auditee’s Comments on Finding We agree with the auditors’ finding. Corrective Action We will follow procedure...
Finding 2024-002 Federal Agency U.S. Department of Housing and Urban Development Federal Program Community Project Funding Compliance Requirements E - Eligibility Finding Type Federal Awards Auditee’s Comments on Finding We agree with the auditors’ finding. Corrective Action We will follow procedures to ensure program eligibility and we will review the accuracy / completion of the documentation being processed in our participant files on a periodic basis. Anticipated Completion Date November 30, 2025
Views of Responsible Officials: CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. CIF made adjustments and improvements in this area during FY 25. CIF’s FY 25 Audit Report will be ...
Views of Responsible Officials: CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. CIF made adjustments and improvements in this area during FY 25. CIF’s FY 25 Audit Report will be submitted to the FAC prior to the deadline, clearing this finding in the FY 25 Audit Report.
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