Corrective Action Plans

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Views of Responsible Officials and Planned Corrective Actions: Management agrees documentation must be retained. Corrective Action: Management has implemented a formal process to document vendor eligibility verficiation. As of FY 2025, all vendors are revewied in SAM. gov prior to payment or contrac...
Views of Responsible Officials and Planned Corrective Actions: Management agrees documentation must be retained. Corrective Action: Management has implemented a formal process to document vendor eligibility verficiation. As of FY 2025, all vendors are revewied in SAM. gov prior to payment or contract execution, and a screenshot or PDF of the verification is saved to the Vendor Verification Log. The Grants & Finance Manager maintains this documentation as part of the procurement file.
Management has addressed the issue by recertifying the tenants and does not expect late recertifications to occur again.
Management has addressed the issue by recertifying the tenants and does not expect late recertifications to occur again.
For ALN 16.575 Crime Victim Assistance There was a staffing change for the program after FY23-24. Since the new Program Manager joined in December 2023, she worked with her team to put together the following procedures and protocols: For direct program expenses, all copies of rent payment requests, ...
For ALN 16.575 Crime Victim Assistance There was a staffing change for the program after FY23-24. Since the new Program Manager joined in December 2023, she worked with her team to put together the following procedures and protocols: For direct program expenses, all copies of rent payment requests, check stubs and client signed half sheets are retained. Client support purchases have original receipts. For proof of client eligibility, the previous management team kept the files in paper format. The new management team saved all the copies of client IDs, birth certificates or passports in AWARDS to verify age of participants. Client agreements are saved electronically in AWARDS. Paper copies are stored in locked cabinets as well. All time entries are reviewed, approved, submitted, processed and saved in Paycom.
View Audit 371876 Questioned Costs: $1
For ALN 21.027 Coronavirus State and Local Fiscal Recovery, There was a staffing change for the program between June to September 2024. The new program team met with the OSH’s fiscal team to review billing requirements and spending guidelines in the beginning of FY24-25. Starting October 2024, the n...
For ALN 21.027 Coronavirus State and Local Fiscal Recovery, There was a staffing change for the program between June to September 2024. The new program team met with the OSH’s fiscal team to review billing requirements and spending guidelines in the beginning of FY24-25. Starting October 2024, the new program team followed the guideline to restrict allowable expenses for clients only to the following: ● Tenant rent portion only on an emergency or as needed basis ● Move in deposit ● Housing application fees In FY24-25, clients came from referrals from OSH as agreed upon. Client eligibility is verified by data in HMIS by the program team. Client files are stored in locked cabinets in the program team’s office. All time entries are reviewed, approved, submitted, processed and saved in Paycom.
View Audit 371876 Questioned Costs: $1
Internal controls will be created to ensure that the Quarterly Compliance Reports agree to internal supporting documents and that reports will be submitted timely.
Internal controls will be created to ensure that the Quarterly Compliance Reports agree to internal supporting documents and that reports will be submitted timely.
Internal controls will be created for reviewing the determination of eligibility for participation in the Emergency Rental Assistance Program.
Internal controls will be created for reviewing the determination of eligibility for participation in the Emergency Rental Assistance Program.
Finding 2024-006 Compliance Requirement: Special Tests and Provisions-Sliding Fee Discounts Significant Deficiency Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 US Department of Health and Human Services Condition: Of the twenty-five-patients selected for testi...
Finding 2024-006 Compliance Requirement: Special Tests and Provisions-Sliding Fee Discounts Significant Deficiency Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 US Department of Health and Human Services Condition: Of the twenty-five-patients selected for testing the Federal Poverty Guideline (FPG) was inaccurately applied for two patients. Action Planned in Response to the Finding: In the past year, the collection and retention of sliding fee discount qualifying documents have been integrated and the calculation performed by the clinic’s electronic medical record system. An employee was added, in part, to provide oversite of the sliding discount process. Official Responsible for Ensuring the CAP: Darian Davis Planned Completion Date: December 2025
To address the noted deficiencies in the late submissions to HUD and the FAC, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prior...
To address the noted deficiencies in the late submissions to HUD and the FAC, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prioritized needed corrections in May and June 2025, transitioned from MRI software to Yardi software as of June 2025, sent Occupancy Specialists to a 2 ½ day Quadel training to review all the basic requirements of HUD in July 2025, and we continue to provide internal training and process orientation to Occupancy Specialists. In addition, we will continue to ensure all Standard Operating Procedures are followed. This oversight will be provided by all supervisors, re-establish the regular reviews of new tenant files outlined in the SOP “OCC-05 Occupancy File Reviews,” and continue internal training for staff as needed.
To address the noted deficiencies in the late submissions to HUD and the FAC, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prior...
To address the noted deficiencies in the late submissions to HUD and the FAC, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prioritized needed corrections in May and June 2025, transitioned from MRI software to Yardi software as of June 2025, sent Occupancy Specialists to a 2 ½ day Quadel training to review all the basic requirements of HUD in July 2025, and we continue to provide internal training and process orientation to Occupancy Specialists. In addition, we will continue to ensure all Standard Operating Procedures are followed. This oversight will be provided by all supervisors, re-establish the regular reviews of new tenant files outlined in the SOP “OCC-05 Occupancy File Reviews,” and continue internal training for staff as needed.
To address the noted deficiencies in tenant file documentation, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prioritized needed ...
To address the noted deficiencies in tenant file documentation, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prioritized needed corrections in May and June 2025, transitioned from MRI software to Yardi software as of June 2025, sent Occupancy Specialists to a 2 ½ day Quadel training to review all the basic requirements of HUD in July 2025, and we continue to provide internal training and process orientation to Occupancy Specialists. In addition, we will continue to ensure all Standard Operating Procedures are followed. This oversight will be provided by all supervisors, re-establish the regular reviews of new tenant files outlined in the SOP “OCC-05 Occupancy File Reviews,” and continue internal training for staff as needed.
An age waiver has been submitted to HUD and is currently being reviewed. We are awaiting their decision. While we await a decision, Meadow Lane will review all existing application for eligibility and advise any existing applicants who are not of age that they are no longer eligible via mail.
An age waiver has been submitted to HUD and is currently being reviewed. We are awaiting their decision. While we await a decision, Meadow Lane will review all existing application for eligibility and advise any existing applicants who are not of age that they are no longer eligible via mail.
Food Distribution Cluster– Assistance Listing No. 10.565, 10.568, and 10.569 Recommendation: We recommend the County review controls and procedures surrounding the programs including review and record retention requirements. Explanation of disagreement with audit finding: There is no disagreement wi...
Food Distribution Cluster– Assistance Listing No. 10.565, 10.568, and 10.569 Recommendation: We recommend the County review controls and procedures surrounding the programs including review and record retention requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will develop and implement new policy and procedures to appropriate review and record retention. Names of the contact persons responsible for corrective action: Tanya Gurule Planned completion date for corrective action plan: December 31st, 2025
Finding 2024-2 a. Statement of Condition In connection with our review of 1 lease file for move-ins we noted the following deficiency: 1 file did not have timely income verification through Enterprise Income Verification System (EIV). b. Action(s) Taken or Planned on the Finding Management plans to ...
Finding 2024-2 a. Statement of Condition In connection with our review of 1 lease file for move-ins we noted the following deficiency: 1 file did not have timely income verification through Enterprise Income Verification System (EIV). b. Action(s) Taken or Planned on the Finding Management plans to implement a system to track EIV verification to ensure compliance with tenant eligibility requirements within the 90-day deadline.We will provide ongoing training and support to staff to ensure that the updated rules and regulations on tenant eligibility are followed.
Management Response/Corrective Action Plan: During the audit period, the City was in the process of transitioning to a virtual inspection and project management platform designed to retain inspection reports, photographs, and supporting documentation in a centralized and permanent digital file. This...
Management Response/Corrective Action Plan: During the audit period, the City was in the process of transitioning to a virtual inspection and project management platform designed to retain inspection reports, photographs, and supporting documentation in a centralized and permanent digital file. This system is now in place and used for all HUD activity record keeping assuring records are consistently documented and readily accessible for compliance and monitoring purposes. Following the audit period, the City ultimately discontinued direct administration of housing rehabilitation programs under the CDBG entitlement. As a result, the risk of missing pre-rehabilitation inspection documentation for City-managed activities has been eliminated.
The discrepancies identified were the result of inconsistencies between internal student records and data transmitted to COD for Direct Loan origination. These errors occurred due to manual data entry and timing differences between updates made in the institution’s student information system (SIS) a...
The discrepancies identified were the result of inconsistencies between internal student records and data transmitted to COD for Direct Loan origination. These errors occurred due to manual data entry and timing differences between updates made in the institution’s student information system (SIS) and those reflected in COD. Financial Aid staff received refresher training on Direct Loan data accuracy, COD reporting requirements, and verification procedures to ensure consistent documentation and communication between systems. Collaboration with IT Office is underway to establish automated data checks between the SIS and COD files to minimize the risk of future mismatches. Implementation of the corrective action plan is expected to be complete by June 30, 2026. Responsible Party Robert Rood Interim Vice President Finance and Administration
Finding Number 2024-001: Eligibility Determination Process (Material weakness in Internal Control over Compliance and Material Noncompliance – Eligibility) Program: Housing Opportunities for Persons with AIDS Assistance Listing Number: 14.241 Response and Corrective Action Plan: Management agrees wi...
Finding Number 2024-001: Eligibility Determination Process (Material weakness in Internal Control over Compliance and Material Noncompliance – Eligibility) Program: Housing Opportunities for Persons with AIDS Assistance Listing Number: 14.241 Response and Corrective Action Plan: Management agrees with the finding that the internal controls required for this program had material weaknesses. To ensure proper program management, program staff have created appropriate procedures and processes to demonstrate internal controls. These include a manager review of potential clients, a checklist for ensuring that the program collects and maintains required records, and a procedure for collecting and storing third-party documentation for client program intake/eligibility, diagnosis, and income. Anticipated Completion Date: by September 1, 2025 Responsible Person: Tiffany Major, Deputy Director
Finding 2024-003 Significant Deficiency in Internal Control Over Compliance – Eligibility Application Review Questioned Programs ALN 84.250 American Indian Vocational Rehabilitation Services Agencies: Department of Education Award Numbers H250N210051- Year 2023 H250N210051- Year 2024 Condition The A...
Finding 2024-003 Significant Deficiency in Internal Control Over Compliance – Eligibility Application Review Questioned Programs ALN 84.250 American Indian Vocational Rehabilitation Services Agencies: Department of Education Award Numbers H250N210051- Year 2023 H250N210051- Year 2024 Condition The Association is not consistently following their own internal control procedures for keeping evidence of reviewing the eligibility certification form. Status In Progress Management’s Corrective Action Plan Vocational Rehabilitation (VR) will update its required document checklist to include a check for required signatures. The intake staff will utilize the checklist for its first level of application intake to ensure all supporting documents are included and the application is complete, including required signatures. Another step VR will add in the process is a second level of review. Each application that has been approved for support will be reviewed by a second reviewer before final approval. Further, each application that exceeds an award of $10,000, will be reviewed by a third approver. Since applications for services are sometimes foreword to AVCP VR by the Yukon Kuskokwim Health Corporation Audiology Department, AVCP VR will conduct regular training to Audiology staff on the correct process for completing its application. Internally, AVCP VR will continue to conduct yearly training to Village based AVCP staff, who sometimes accept and forward applications to the VR staff, on the correct process for completing its application. Lastly, AVCP VR will update its internal policies and procedures to include these four key steps to ensure applications are complete and signed
Will speak to Department Heads and make sure that the language is added to contracts in regard to suspension and debarment. Will also have a form for vendors to sign if purchasing products. If we are not able to have the first two options done will be sure to use SAM.gov to look up information prior...
Will speak to Department Heads and make sure that the language is added to contracts in regard to suspension and debarment. Will also have a form for vendors to sign if purchasing products. If we are not able to have the first two options done will be sure to use SAM.gov to look up information prior to ordering and take screen shots showing the date. An SOP will be written up and provided to auditors to make sure we are complying with requirements.
View Audit 371154 Questioned Costs: $1
Condition: Pell Grant disbursement data was not submitted to COD within the 15-day federal requirement due to a system error. Corrective Action: The Financial Aid Office, in collaboration with Bursar, will implement an automated alert system to flag pending COD submissions and conduct reconcilitions...
Condition: Pell Grant disbursement data was not submitted to COD within the 15-day federal requirement due to a system error. Corrective Action: The Financial Aid Office, in collaboration with Bursar, will implement an automated alert system to flag pending COD submissions and conduct reconcilitions twice monthly. Responsible Party: Director of Financial Aid and Bursar Completion Date: January 31, 2026 Monitoring: Monthly COD reporting review with Vice President for Administration & Finance.
Congressionally Mandated Projects - Assistance Listing #66.202 Recommendation: We recommend that the City strengthen its internal controls over federal reporting requirements to ensure timely compliance with all federal reporting deadlines. Explanation of disagreement with audit finding: There is no...
Congressionally Mandated Projects - Assistance Listing #66.202 Recommendation: We recommend that the City strengthen its internal controls over federal reporting requirements to ensure timely compliance with all federal reporting deadlines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Department personnel inquired, through their contact for the grant, about the reporting requirements. Multiple reimbursement requests were submitted and the all payments were received. No notification was received regarding any missing reports. As of 7/24/2025, all reporting was up to date. Name(s) of the contact person(s) responsible for corrective action: Angie Murray Planned completion date for corrective action plan: 7/24/2025
Management agrees with the finding and will evaluate expenditures of federal awards each year to ensure the filings are done timely.
Management agrees with the finding and will evaluate expenditures of federal awards each year to ensure the filings are done timely.
United States Department of Education Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Condition: 2 students of the 22 students selected for eligibility did not maintain academic satisfactory progress and were on probation but did not receive notifications. Audit...
United States Department of Education Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Condition: 2 students of the 22 students selected for eligibility did not maintain academic satisfactory progress and were on probation but did not receive notifications. Auditors’ Recommendation: We recommend that the University review its satisfactory academic progress policy to ensure that all notifications are completed as required. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented a new SIS and Financial Aid processing system. Name(s) of the contact person(s) responsible for corrective action: Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2025
We have changed the process so all contracts are collected at the SAU central office to ensure completeness.
We have changed the process so all contracts are collected at the SAU central office to ensure completeness.
View Audit 370927 Questioned Costs: $1
Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007, 84.033 Recommendation: We recommend the College strengthen its internal controls to ensure timely identification of students not meeting SAP standards. Additionally, the College should work with its system administ...
Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007, 84.033 Recommendation: We recommend the College strengthen its internal controls to ensure timely identification of students not meeting SAP standards. Additionally, the College should work with its system administrator to resolve the SAP calculation issue or implement an alternative method for tracking SAP compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CGCC has completed a thorough review of its Satisfactory Academic Progress (SAP) policy to ensure alignment with the capabilities and limitations of our current system. We remain committed to resolving ongoing system-related issues and are actively keeping the policy and system functionality in sync as improvements are made. The issue regarding SAP not calculating correctly is still in progress. We have been working closely with Anthology to identify and implement long-term solutions. Unfortunately, the necessary fixes require significant time and manual intervention. Despite these challenges, we have made progress: as of Spring 2025, we are now able to accurately identify affected students—something that was not possible during the 2023–2024 award year. Additionally, we are in the process of hiring a Financial Aid Director. This added leadership and support will help us address the remaining issues more efficiently and continue making meaningful progress toward full resolution Name(s) of the contact person(s) responsible for corrective action: Denise Reid-Strachan Planned completion date for corrective action plan: 9/1/2025
View Audit 370896 Questioned Costs: $1
Finding 2024-03 Insufficient Documentation Supporting Payroll Activity Condition: During testing of payroll claims, we noted that the Organization did not consistently maintain documentation of approved pay rates. Some employees had offer letters on file, while others did not. In certain cases, the ...
Finding 2024-03 Insufficient Documentation Supporting Payroll Activity Condition: During testing of payroll claims, we noted that the Organization did not consistently maintain documentation of approved pay rates. Some employees had offer letters on file, while others did not. In certain cases, the offer letters on file contained pay rates that did not match the actual pay rates being paid. Although our procedures and inquiries confirmed that employees were paid the correct amounts in accordance with approved procedures, the approved documentation was not consistently retained. In addition, we noted that the Organization did not maintain properly completed and approved I-9 forms for all employees during the year. Corrective Actions Taken or Planned: The organization recognizes the importance of maintaining complete and accurate payroll documentation and acknowledges the deficiencies identified during the audit. While payroll payments were made accurately, we recognize that inconsistent retention of supporting documentation created a compliance risk. Certain documentation had been maintained in digital form by a former staff member. Due to staff turnover, these records were not readily accessible or able to be located during the audit period. Management has since initiated a process to update all employee files with current, complete, and properly executed documentation to ensure compliance and improve recordkeeping practices. Management and leadership remain committed to strengthening personnel file management, maintaining all required documentation in accordance with applicable regulations, and reinforcing oversight to prevent recurrence in future audit periods. The Organization plans to execute the following: 1. Standardization of Employee Files - The Organization has implemented a standardized checklist for all employee personnel files to ensure the presence of: + Signed offer letters with approved pay rates + Completed and verified I-9 forms + Any subsequent pay rate change approvals - Co-Executive Directors will be required to complete and sign the checklist for each employee file upon hire, and again during annual compliance reviews. 2. Offer Letter and Pay Rate Documentation - Effective immediately, all employees (existing and new) will have a signed offer letter or addendum on file reflecting their current pay rate. - For employees where discrepancies exist between historical offer letters and current pay, updated pay rate addendums will be drafted, signed by both employee and management, and placed in their personnel files. 3. I-9 Form Compliance - The organization will perform a full review of all current employee I-9 documentation to identify and correct any missing or incomplete forms. - Going forward, I-9 forms will be completed and verified on or before the employee’s first day of work, in accordance with federal requirements. - An annual HR compliance audit will be conducted to ensure all I-9’s are up to date and retained properly. 4. Training & Accountability - Administrative staff will receive refresher training on employment documentation requirements, including I-9 compliance and payroll authorization documentation. - The Co-Executive Directors will review a sample of personnel files quarterly to verify compliance and hold Co-Executive Directors accountable for maintaining accurate documentation. To ensure continued compliance, the Organization will maintain a centralized file tracking system, updated quarterly, and report results to the Board. Corrective actions will be taken immediately if gaps are identified.
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