Corrective Action Plans

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2025-001: Missing Exit Counseling Documentation - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2025 Condition Found During our student file testing, we noted four students out of forty did not have documentation in their f...
2025-001: Missing Exit Counseling Documentation - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2025 Condition Found During our student file testing, we noted four students out of forty did not have documentation in their file that exit counseling was sent thirty days after the student withdrew. We consider the missing exit counseling to be a instance of noncompliance with the Eligibility Compliance Requirement. This is a repeat finding, see Prior Year Audit Findings 2024-002. Corrective Action Plan LLCC has developed reports to identify students who require exit counseling. The Financial Aid Compliance Coordinator is responsible for overseeing and administering exit counseling process for students who are graduating, withdrawing, or dropping below half-time enrollment. Responsibilities include ensuring compliance with federal regulations, providing accurate loan repayment information, and maintaining proper documentation of completed counseling sessions. Responsible Person for Corrective Action Plan Alison Mills Implementation Date of Corrective Action Plan FY26
Corrective Action Plan (Management Response): The District acknowledges the finding and has initiated corrective measures:1. Policy Development: Draft comprehensive written policies and procedures addressing procurement, allowable costs, eligibility, reporting, and record retention for all major fed...
Corrective Action Plan (Management Response): The District acknowledges the finding and has initiated corrective measures:1. Policy Development: Draft comprehensive written policies and procedures addressing procurement, allowable costs, eligibility, reporting, and record retention for all major federal programs. 2. Approval and Adoption: Policies will be reviewed and formally adopted by the Board of Trustees prior to acceptance of further federal grants. 3. Training and Implementation: Staff responsible for federal program administration will be trained on the new procedures. Training materials will include checklists and step by step guides to ensure consistent application. 4. Monitoring: The District will conduct quarterly reviews of federal programs (if applicable) to ensure compliance. Exceptions will be documented and corrective action taken immediately.
Corrective Action MHA is now fully staffed with a current recertification reporting rate of over 96%. New staff members have been hired, trained and fully onboarded. An outside consultant was retained prior to staff hiring and processed all delinquent recertifications in the spring of 2025. Addition...
Corrective Action MHA is now fully staffed with a current recertification reporting rate of over 96%. New staff members have been hired, trained and fully onboarded. An outside consultant was retained prior to staff hiring and processed all delinquent recertifications in the spring of 2025. Additional staff training is being scheduled. Increased quality control procedures are being designed and implemented in coordination with a consultant to ensure ongoing activities meet Authority standards as well as Federal requirements.
View Audit 374083 Questioned Costs: $1
Tenant files have not regularly been reviewed for QC. Management will immediately set up regular reviewing of random files to be sure files are processed correctly and rents are being calculated according to HUD guidelines. Management agrees with the finding and takes the recommendations of the audi...
Tenant files have not regularly been reviewed for QC. Management will immediately set up regular reviewing of random files to be sure files are processed correctly and rents are being calculated according to HUD guidelines. Management agrees with the finding and takes the recommendations of the auditor to correct it.
Tenant files have not regularly been reviewed for QC. Management will immediately set up regular reviewing of random files to be sure files are processed correctly and rents are being calculated according to HUD guidelines. Management agrees with the finding and takes the recommendations of the audi...
Tenant files have not regularly been reviewed for QC. Management will immediately set up regular reviewing of random files to be sure files are processed correctly and rents are being calculated according to HUD guidelines. Management agrees with the finding and takes the recommendations of the auditor to correct it.
Finding 2025-002 - Accounting Controls - capital Fund Grant Management (Cash Management)-ALN 14.872 Public Housing capital Fund - Noncompliance and Significant Deficiency Corrective Action Plan: AHC has assigned two Senior Managers with eloccs secure system) access. Person Responsible: Shlrley Hende...
Finding 2025-002 - Accounting Controls - capital Fund Grant Management (Cash Management)-ALN 14.872 Public Housing capital Fund - Noncompliance and Significant Deficiency Corrective Action Plan: AHC has assigned two Senior Managers with eloccs secure system) access. Person Responsible: Shlrley Henderson, Deputy Director, Arnesha Nuniss and Abe Singh, Ex. Dir. Who is waiting for his eloccs access Anticipated Completion Date: September 10, 2025.
Finding 2025-002 The Authority agrees with the finding and responds stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies and ac...
Finding 2025-002 The Authority agrees with the finding and responds stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies and accepts them.
2025-03/2024-003 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS10591 Program Years 17 and 18 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g...
2025-03/2024-003 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS10591 Program Years 17 and 18 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Recommendation – We recommend management continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale and the Health Center Program Compliance Manual. Views of Responsible Officials and Planned Corrective Actions – CCI is implementing a system update within eCW to ensure the sliding fee schedule is accurately configured and consistently applied across all service locations. As part of this corrective action, CCI is developing a formal training program to ensure that all applicable employees understand the sliding fee requirements and possess the necessary knowledge to follow the established procedures. CCI is also establishing an internal review process to monitor compliance with the sliding fee policy. This process will include periodic sampling and review of sliding fee scale assessments to verify that eligibility determinations and discounts are being applied correctly and in accordance with policy. Any identified discrepancies will be addressed through targeted staff retraining or process adjustments, as appropriate. These corrective actions are designed to strengthen internal controls, ensure consistent application of the sliding fee program, and maintain compliance with regulatory and organizational requirements. Reason for Recurrence – CCI experienced significant turnover within the Revenue Cycle Department during fiscal year 2025, which contributed to delays in updating system configurations and conducting required reviews. Anticipated Completion/Implementation Date: End of Fiscal Year 2026
2025-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Shigeyuki Murota, Patient Accounts Manager: George Ward Corrective Action: San Francisco Medical Center Outpatient Improvement Programs, Inc. d/b/a Equity Health will: - Update the Sliding Fee Discou...
2025-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Shigeyuki Murota, Patient Accounts Manager: George Ward Corrective Action: San Francisco Medical Center Outpatient Improvement Programs, Inc. d/b/a Equity Health will: - Update the Sliding Fee Discount Program (SFDP) policies, procedures, and forms for better clarity and tracking. - Continue to perform monthly internal audits of sliding fee transactions and document audit findings, corrective actions, and report results to leadership. - Retrain current staff quarterly based on the monthly internal audit results. - Train all new staff at new hire orientations. - Validate staff understanding through annual knowledge checks and competency assessments. - Integrate SFDP compliance into staff performance evaluations. - Maintain centralized log of all SFDP applications and determinations. Proposed Completion Date: December 31, 2025
1. Correcting Plan Food and Nutrition Service Coordinator will review applications and supporting documentation for completion and eligibility accuracy. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Insuring C...
1. Correcting Plan Food and Nutrition Service Coordinator will review applications and supporting documentation for completion and eligibility accuracy. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Insuring CAP The Food and Nutrition Service Coordinator. 4. Planned Completion Date for CAP The CAP was implemented immediately during audit fieldwork performed in October 2025. 5. Plan to Monitor Completion of CAP The Food and Nutrition Service Coordinator will continually review applications and supporting documentation for completion and eligibility accuracy. Any issues noted will be communicated to appropriate staff and fixed immediately.
Our Financial Aid Director will implement an independent review process for those students for whom professional judgment is applied when calculating student financial aid benefits.
Our Financial Aid Director will implement an independent review process for those students for whom professional judgment is applied when calculating student financial aid benefits.
View Audit 373203 Questioned Costs: $1
Effective September 15, 2025 the District Treasurer will check the status of all vendors associated to the Child Nutrition program. In cooperation with the Food Service Director, the District Treasurer will review eligibility of any vendors that are requested to be used. Any vendor that is found not...
Effective September 15, 2025 the District Treasurer will check the status of all vendors associated to the Child Nutrition program. In cooperation with the Food Service Director, the District Treasurer will review eligibility of any vendors that are requested to be used. Any vendor that is found not to be eligibility list will be reported to the Food Service Director and Purchasing Agent. This list will be updated and checked annually.
The District will review the requirements of 2 CFR Section 200.214 and 2 CFR Part 180 and ensure that a review of the eligibility of potential vendors to participate in Federal assistance programs or activities is performed prior to disbursing funds to the vendor. This will be verified on an annual ...
The District will review the requirements of 2 CFR Section 200.214 and 2 CFR Part 180 and ensure that a review of the eligibility of potential vendors to participate in Federal assistance programs or activities is performed prior to disbursing funds to the vendor. This will be verified on an annual basis. Anticipated implementation date is October 1, 2025 by responsible person(s) District Business Official and District Treasurer Kelsey Reed.
Sterling Health Solutions (SHS) acknowledges the errors identified and is committed to addressing the underlining reasons that caused them. SHS will review all applicable policies and provide additional training to ensure that all personnel responsible for and involved in the sliding fee discount pr...
Sterling Health Solutions (SHS) acknowledges the errors identified and is committed to addressing the underlining reasons that caused them. SHS will review all applicable policies and provide additional training to ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. SHS will monitor Slide applications on a daily basis and complete, at a minimum, quarterly audits of each clinic’s Slide applications. SHS will provide ongoing training, as necessary, to address any concerns identified during the daily monitoring or quarterly audits.
Return of Title IV (R2T4) Calculations Planned Corrective Action: OFA will implement a process where an additional person will review R2T4 student records to ensure proper return of funds and calculations. OFA and VPAA will develop a process for instructors and Registrar to identify students that di...
Return of Title IV (R2T4) Calculations Planned Corrective Action: OFA will implement a process where an additional person will review R2T4 student records to ensure proper return of funds and calculations. OFA and VPAA will develop a process for instructors and Registrar to identify students that did not begin attendance. Person Responsible for Corrective Action Plan: Stephanie Castillo, Director of Financial Aid Penny Hayes, Vice President of Academic Affairs Anticipated Date of Completion: Spring 2026
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Financial aid will be working closely with the Registrar and the Vice President of Academic Affairs to clean up all current records and CIP codes. The OFA and VPAA will maintain a schedule for upda...
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Financial aid will be working closely with the Registrar and the Vice President of Academic Affairs to clean up all current records and CIP codes. The OFA and VPAA will maintain a schedule for updates of student statuses and CIP codes. The OFA will also use a secondary person to view reports before transmission. OFA will work with NCH to update CIP codes. Person Responsible for Corrective Action Plan: Stephanie Castillo, Director of Financial Aid Penny Hayes, Vice President of Academic Affairs Anticipated Date of Completion: Fall 2026
CONDITION: During uring testing of 40 Pell Grant recipients, two awards were miscalculated--one over-award and one under-award--due to data-entry error and lack of secondary review. Corrective Action: The College has reviewed all Pell awards for the 2024-2025 award year to identify and correct any a...
CONDITION: During uring testing of 40 Pell Grant recipients, two awards were miscalculated--one over-award and one under-award--due to data-entry error and lack of secondary review. Corrective Action: The College has reviewed all Pell awards for the 2024-2025 award year to identify and correct any additional errors. Effective immediately, the Financial Aid Office will: 1. Implement a secondary review of all Pell award calculations prior to disbursement. 2. Reconcile ISIR data to the financial-aid system each term. 3. Provide annual staff training on Pell payment schedules and data accuracy. Documentation of the secondary review will be retained in each student's electronic record.
Oversight Agency for Audit, Jacksonville Towers, Inc., respectfully submits the following corrective action plan for the year ended March 31, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audi...
Oversight Agency for Audit, Jacksonville Towers, Inc., respectfully submits the following corrective action plan for the year ended March 31, 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: April 1, 2024 through March 31, 2025 The finding from the March 31, 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 8 Project Based Rental Assistance, ALN 14.195 Recommendation: The Project should implement procedures to ensure that initial and ongoing tenant eligibility documentation is obtained timely and properly maintained. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and tenant file maintenance 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 Irene Phillips CFO
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Dominique J. Dunn, In...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Dominique J. Dunn, Interim Executive Director, will be responsible to implement this corrective action by March 31, 2026.
View Audit 371807 Questioned Costs: $1
Finding 2025-003 Compliance Requirements A/B – Activities Allowed or Unallowed and Allowable Costs / Cost Principles, E – Eligibility, and N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comments on Finding Auditee has not had time to evaluate Auditor’s finding. Corrective Act...
Finding 2025-003 Compliance Requirements A/B – Activities Allowed or Unallowed and Allowable Costs / Cost Principles, E – Eligibility, and N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comments on Finding Auditee has not had time to evaluate Auditor’s finding. Corrective Action We will keep all required documentation in tenant files and establish processes and procedures to ensure compliance with the provisions in HUD Handbook 4350.3, HUD Handbook 4381.5, and the Regulatory Agreement. Anticipated Completion Date December 31, 2025
2025-004 – Lack of Documentation for SAM.gov Exclusion Checks. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Village did not retain documentation to support that the exclusion checks were per...
2025-004 – Lack of Documentation for SAM.gov Exclusion Checks. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Village did not retain documentation to support that the exclusion checks were performed for vendors. As a result, there is no evidence that the Village verified whether these parties were suspended or debarred prior to entering covered transactions. Auditor Recommendation. We recommend that the Village retain evidence that SAM.gov exclusion checks are being completed for vendors to document that vendors are not suspended or debarred prior to entering covered transactions. Corrective Action. The Village will begin retaining documentation for its SAM.gov exclusion checks that it completes for vendors to verify whether these parties were suspended or debarred prior to entering covered transactions. Responsible Person. Ross Wilson, Village Clerk/Treasurer. Anticipated Completion Date: February 2026.
Finding – Special Tests and Provisions: Enrollment Reporting – Federal Direct Student Loan Program, Assistance Listing Number 84.268; May 31, 2025 Award Year; U.S. Department of Education Criteria or Specific Requirement Enrollment information, including the effective date of separation from the ins...
Finding – Special Tests and Provisions: Enrollment Reporting – Federal Direct Student Loan Program, Assistance Listing Number 84.268; May 31, 2025 Award Year; U.S. Department of Education Criteria or Specific Requirement Enrollment information, including the effective date of separation from the institution, must be accurately reported within 30 days whenever attendance changes for a student, unless a roster will be submitted within 60 days. The changes include reductions or increases in attendance levels, withdrawals, graduations, and approved leaves of absence. It is the institution’s responsibility, as a participant in the Title IV aid programs, to monitor and report these changes to the National Student Loan Data System (“NSLDS”). (NSLDS Enrollment Reporting Guide November 2022, and 34 CFR 685.309(b)) Condition Of the nine students selected for enrollment reporting testing, two students within the sample were reported to NSLDS outside the maximum 60-day window. This was not a statistically valid sample. Views of Responsible Officials and Planned Corrective Actions The College concurs with the finding. The College will continue to remain vigilant in its oversight over timely communication of enrollment reporting detail to NSLDS. In both instances, the data we had sent to the National Student Clearinghouse (NSC) was not received by NSLDS in a timely fashion. We will review our reporting schedule and make the appropriate changes to our reporting timeline to ensure the data we report to the NSC is subsequently received by NSLDS within regulations. Names of Contact Person Responsible for Corrective Action: Anna Lyons, Associate Registrar Anticipated Completion Date: September 1, 2025
BOYS & GIRLS CLUBS OF WEBER-DAVIS CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2025 Finding: 2025-001 Name of contact person and title: Angie Pitt Completion date: October 2, 2025 Agency's response: Concur Management's Response: The Boys & Girls Clubs of Weber-Davis has not been required by th...
BOYS & GIRLS CLUBS OF WEBER-DAVIS CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2025 Finding: 2025-001 Name of contact person and title: Angie Pitt Completion date: October 2, 2025 Agency's response: Concur Management's Response: The Boys & Girls Clubs of Weber-Davis has not been required by the grant facilitator to provide member income data. However, to ensure compliance with federal reporting requirements, we will begin requesting income information from our members. In addition, we will reach out to our partner schools to determine whether they can confirm which of our members participate in the free or reduced lunch program.
Recommendation: The Project should perform a review of all tenant files to ensure all tenant files are complete with required documentation. Planned Corrective Actions: High Street Homes, Inc. acknowledges the deficiency related to tenant eligibility documentation. Management recognizes the importan...
Recommendation: The Project should perform a review of all tenant files to ensure all tenant files are complete with required documentation. Planned Corrective Actions: High Street Homes, Inc. acknowledges the deficiency related to tenant eligibility documentation. Management recognizes the importance of maintaining complete tenant files to ensure compliance with HUD requirements. Corrective actions taken include: • Immediate review of all current tenant files to confirm lease agreements and all required HUD forms are properly executed and on file. • Establishment of a tenant file checklist to ensure all required documentation is obtained and reviewed prior to tenant move-in. • Implementation of supervisory review of tenant files to verify completeness before occupancy is finalized. • Staff training on HUD eligibility and documentation requirements to reinforce compliance. High Street Homes, Inc. is committed to ensuring full compliance with HUD tenant eligibility documentation requirements.
Need Analysis Planned Corrective Action: 1. A revised internal procedure has been implemented, requiring a secondary review of all loan award allocations prior to disbursement to confirm compliance with federal regulations. 2. Staff members responsible for loan origination and packaging have been as...
Need Analysis Planned Corrective Action: 1. A revised internal procedure has been implemented, requiring a secondary review of all loan award allocations prior to disbursement to confirm compliance with federal regulations. 2. Staff members responsible for loan origination and packaging have been assigned refresher training on federal loan awarding requirements, with specific emphasis on annual and aggregate loan limits and the prioritization of subsidized eligibility. 3. System-level reports have been created to identify potential discrepancies in loan allocation, which will be reviewed monthly by the Financial Aid Office. Ongoing Monitoring: The Director of Financial Aid will oversee the monitoring process each term to ensure compliance with 34 CFR 685.203, and 34 CFR 685.301 requirements. Any discrepancies identified will be corrected immediately and documented as part of the institution’s internal compliance log. North Greenville University believes these corrective measures address the issue identified and will prevent recurrence of similar errors. Person Responsible for Corrective Action Plan: Cindi Patterson, Director of Financial Aid Anticipated Date of Completion: October 1, 2025
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