Corrective Action Plans

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VIDOL concurs with the auditor’s findings and recommendations. VIDOL entered a one (1) year contract with Quantum Technology on July 15, 2025, to convert all VIDOL files from a paper based to an electronic recordkeeping system. Quantum Technology continues to digitize and transfer the files to a dat...
VIDOL concurs with the auditor’s findings and recommendations. VIDOL entered a one (1) year contract with Quantum Technology on July 15, 2025, to convert all VIDOL files from a paper based to an electronic recordkeeping system. Quantum Technology continues to digitize and transfer the files to a database where they are properly catalogued, retrievable and indexed in accordance with established naming conventions. Once Quantum Technology completes the contract deliverables, VIDOL will have a robust document management system to facilitate easy retrieval and secure storage.
The Government concurs with the auditor’s findings and recommendations. The Department did not maintain a centralized repository for eligibility documentation. Supporting documentation and related source documents were maintained in various locations and formats, resulting in instances where complet...
The Government concurs with the auditor’s findings and recommendations. The Department did not maintain a centralized repository for eligibility documentation. Supporting documentation and related source documents were maintained in various locations and formats, resulting in instances where complete documentation was not readily available during the audit review. The Department of Planning and Natural Resources (DPNR) with the support of the federal agency’s consultant will implement a centralized electronic repository system to serve as the official recordkeeping location for all eligibility requests and supporting documentation. This repository will house all documents necessary to substantiate eligibility, including but not limited to: • Participant eligibility applications and supporting documentation; • Eligibility determination forms and approval records; • Documentation of eligibility reviews and supervisory approvals; • Complete participant listings containing all relevant information necessary to support eligibility determinations; • Periodic recertification or re-evaluation documents, where applicable; • Correspondence and any additional supporting records required by the grant agreement or Federal regulations.
procedures to ensure payments are clearly identifiable by participant and reconciled to approved eligibility records before assistance is provided. Each payment will be supported by participant identification, eligibility approval, assistance type, approved amount, funding source, payment date, and ...
procedures to ensure payments are clearly identifiable by participant and reconciled to approved eligibility records before assistance is provided. Each payment will be supported by participant identification, eligibility approval, assistance type, approved amount, funding source, payment date, and supporting documentation. UCM has established TANF Eligibility Determination Guidelines, a List of Acceptable Documents, and an Assistance Agreement Form to support eligibility determinations and benefit payment documentation. Per VDSS guidance, once eligibility is established at the beginning of the program, a change in status during the participant’s stay does not disqualify the participant from receiving further services. Felony record documentation is not required in the participant file as felony record status is not part of the eligibility requirement per VDSS. Evidence of review and approval will be retained in the participant file. Responsible for Corrective Action: Gina Macanlalay, Director of Family Achievement Program Case Managers Shruti Jha, Senior Director of Finance Liya Tseye & Carmen Romero, Accountants Laura D’Ambrogi, Grants Manager Anticipated Completion Date: Substantially completed as of April 6, 2026. Ongoing payment review, eligibility monitoring, reconciliation, and supervisory review will continue during the program year.
UCM will strengthen internal controls over TANF eligibility determinations by formalizing written procedures that clearly identify the documentation required to support each eligibility criterion before assistance is provided. The procedures will define required documentation for financial eligibili...
UCM will strengthen internal controls over TANF eligibility determinations by formalizing written procedures that clearly identify the documentation required to support each eligibility criterion before assistance is provided. The procedures will define required documentation for financial eligibility, citizenship or qualified alien status, TANF benefit history, household composition, applicable legal eligibility requirements, and work participation requirements when applicable. UCM reviewed and discussed the findings with the auditor, Senior Director of Finance, and Chief Program Officer. UCM also reviewed the Virginia Department of Social Services post-training materials on TANF Employment Advancement Eligibility Determination Training, and clarified identified areas of the findings with the Virginia Department of Social Services as they relate to the subrecipient signed contract. UCM designed new Screening Guidelines for incoming program participants, including a documented supervisory review and approval process, which were completed on April 16, 2026. The new screening guidelines require participant files to include sufficient documentation supporting eligibility determinations and require supervisory review before assistance is provided. A supervisor or designated reviewer will verify that the participant file contains the required eligibility documentation, that eligibility criteria have been met, and that the assistance is consistent with TANF requirements, VDSS guidance, the subrecipient contract, and program guidelines. UCM reviewed and trained staff on the new eligibility screening guidelines, acceptable documents, and income requirements on April 28, 2026. Staff responsible for TANF eligibility determinations, case management, direct assistance, and grant compliance will continue to receive training as needed to ensure they understand TANF documentation requirements and maintain complete and accurate participant files. UCM will also periodically monitor participant files to confirm continued compliance and identify any additional training or process improvements needed. Responsible for Corrective Action: Gina Macanlalay, Director of Family Achievement Program Laura D’Ambrogi, Grants Manager Case Managers VDSS Program Consultant Anticipated Completion Date: Substantially completed as of April 28, 2026. Ongoing implementation, supervisory review, staff training, and monitoring will continue during the program year.
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to establishing a rigorous documentation and oversight framework. We are prioritizing the development of standardized file-handling protocols, the implementation of a uniform record-keeping system, and the execution of comprehensive staff training to...
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to establishing a rigorous documentation and oversight framework. We are prioritizing the development of standardized file-handling protocols, the implementation of a uniform record-keeping system, and the execution of comprehensive staff training to ensure that all sanction-related evidence is preserved, organized, and readily accessible for audit and verification purposes. Action Steps: 1. Implement a new "Uniform Record Retention & Archiving SOP" that mandates a specific organization, labeling, and storage legend for all participant files, ensuring uniform accessibility across all regions. 2. Adopt a formal "Sanction & Work Verification Checklist" that [LP4.1]must be completed for every participant file. This checklist will specifically require the inclusion of sanction periods, justification forms for "just cause," and evidence of non-compliance. 3. Develop an internal tracking log to manage sanction periods. This log will ensure that participants who have failed to comply with the work verification plan are monitored, and payments are suspended or reinstated only upon documented evidence of compliance. 4. Conduct a mandatory regional training curriculum for all regional staff on the importance of file maintenance, the specific requirements for documenting sanctions, and compliance. IMPLEMENTATION DATE During Fiscal Year 2026-2027 RESPONSIBLE PERSON Yessenia Peña Díaz Assistance Secretary of Administration
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to establishing rigorous documentation and archiving framework. We are prioritizing the development of standardized file-handling protocols, the implementation of a uniform record-keeping system, and the execution of comprehensive staff training to e...
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to establishing rigorous documentation and archiving framework. We are prioritizing the development of standardized file-handling protocols, the implementation of a uniform record-keeping system, and the execution of comprehensive staff training to ensure that all eligibility and non-cooperation evidence is preserved, organized, and readily accessible for audit and verification purposes. Action Steps: 1. Implement a new "Uniform Record Retention & Archiving SOP" that mandates a specific organization, labeling, and storage legend for all participant files, ensuring uniform accessibility across all regions. 2. Revise the Eligibility Documentation Checklist that must be completed for every participant, specifically requiring proof of child support referrals and, where applicable, non-cooperation determinations. 3. Formalize the communication protocol between the IV-A (ADSEF) and IV-D (Child Support) agencies to ensure prompt notification and documentation of non-cooperation instances, as required by 45 CFR §264.30(b). 4. Conduct a mandatory regional training curriculum for all regional staff on the importance of file maintenance, the specific requirements for child support referrals, and the legal protocols for handling non-cooperation cases. IMPLEMENTATION DATE During Fiscal Year 2026-2027 RESPONSIBLE PERSON Gerhil Medina Baez Auxiliary Administrator Operational Services
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to establishing a verification framework. We are prioritizing the formalization of inter-agency data sharing agreements, the implementation of standardized income validation protocols, and the execution of a comprehensive training program to ensure a...
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to establishing a verification framework. We are prioritizing the formalization of inter-agency data sharing agreements, the implementation of standardized income validation protocols, and the execution of a comprehensive training program to ensure all regional staff adhere to federal IEVS requirements. Action Steps: 1. MOU Formalization – Execute and maintain active Memoranda of Understanding (MOUs) with all relevant agencies to secure legal access to real-time wage, unemployment, and benefit data. 2. Develop and mandate a new "Income Eligibility Validation SOP". This protocol will strictly forbid reliance on sworn statements alone and will require technicians to cross-reference application data against verified external agency sources. 3. Integrated Data Exchange Protocol – Implement a recurring, automated schedule for the ingestion of SWICA, UC, and BENDEX/SSA data into our internal eligibility systems, ensuring data is available to technicians at the point of application and during quarterly reviews. 4. Implement a Training Curriculum – Launch a recurring, mandatory training program for all regional eligibility technicians and supervisors, focusing on federal IEVS requirements, standardized data validation procedures, and the legal consequences of non-compliance. 5. Implement a monthly "Eligibility Quality Assurance" review, where central-level management audits a sample of case files to ensure that income has been verified against external sources as required by the State Plan. IMPLEMENTATION DATE During Fiscal Year 2026-2027 RESPONSIBLE PERSON Eddie J. Burgos Auxiliary Administrator for Finance and Budget Carlos Martinez Colón Finance Director Vanessa Ayala Gerena Director of Budget Gerhil Medina Baez Auxiliary Administrator Operational Services
VIEWS OF RESPONSIBLE OFFICIALS ADFAN reaffirms its commitment to strengthening its financial reporting processes and ensuring full compliance with federal requirements. The agency will ensure that the SF 425 is completed using the appropriate accounting basis consistent with the financial system in ...
VIEWS OF RESPONSIBLE OFFICIALS ADFAN reaffirms its commitment to strengthening its financial reporting processes and ensuring full compliance with federal requirements. The agency will ensure that the SF 425 is completed using the appropriate accounting basis consistent with the financial system in use, and that all reported expenditures reconcile accurately with the accounting database. A reviewer will be designated to support the verification of information entered by the preparer, and a structured review process will be implemented prior to report submission. These corrective actions will be undertaken while acknowledging the current staffing limitations within the finance area and the ongoing revision of the Procedures Manual. Interim operational guidance will be provided to personnel to promote consistency and compliance until the updated manual is finalized. IMPLEMENTATION DATE December 31, 2026 RESPONSIBLE PERSON José A. Ruiz Quiñones, Interim Director of Finance
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to establishing a rigorous compliance framework to ensure all participant files are complete, accurate, and readily available for audit as required by federal regulations. Action Step: 1. Standardized Documentation Checklist- Implement a mandatory, u...
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to establishing a rigorous compliance framework to ensure all participant files are complete, accurate, and readily available for audit as required by federal regulations. Action Step: 1. Standardized Documentation Checklist- Implement a mandatory, uniform "Eligibility Documentation Checklist" that must be completed for 100% of non-PAN/TANF applicants, ensuring ID, residency, and utility evidence are present before approval. 2. Supervisory Sign-off - Require a supervisor to perform a "Document Completeness Review" for every non-PAN/TANF file before the benefit is authorized. Files lacking mandatory documentation will be rejected by the system/workflow automatically. 3. Analysis of the Existing File Uniformity Procedure for Compliance Verification – Assessment of the physical and digital filing layout across all regions. A uniform legend and organization protocol will be mandated to facilitate monitoring and eliminate systemic filing errors. 4. Compliance Training - Execute mandatory, recurring training sessions for all regional staff on document requirements and the legal necessity of preserving records for the full three-year federal mandate. IMPLEMENTATION DATE During Fiscal Year 2026-2027 RESPONSIBLE PERSON Blanca M. Medina Díaz Administrator Gerhil Medina Baez Auxiliary Administrator Operational Services Marta Soto Ayala NAP Program Director Johana Hernandez Andaluz TANF Program Director
VIEWS OF RESPONSIBLE OFFICIALS ACUDEN is committed to reinforcing our eligibility determination process by standardizing review workflows. We are prioritizing the completion of all missing documentation for affected files and ensuring that every future Eligibility Certificate reflects the required t...
VIEWS OF RESPONSIBLE OFFICIALS ACUDEN is committed to reinforcing our eligibility determination process by standardizing review workflows. We are prioritizing the completion of all missing documentation for affected files and ensuring that every future Eligibility Certificate reflects the required technical and supervisory validations to guarantee compliance. The following corrective actions will be implemented: 1. ACUDEN will recruit at least two (2) staff members to support the implementation of the eligibility verification protocol and ensure adequate capacity for document review. 2. A verification protocol will be established to confirm that all required supporting documents are present and complete prior to finalizing eligibility determinations. A standardized checklist will be created to ensure no document is missing, including during data migration processes. 3. ACUDEN will implement a mandatory dual- verification procedure for all Eligibility Certificates, requiring both the Technician and the Coordinator to sign prior to issuance. IMPLEMENTATION DATE September 2026 RESPONSIBLE PERSON Child Care Director – Sidnia Velez Assistant Administrator for Human Resources – Alex Lopez
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to a comprehensive transformation of our eligibility lifecycle. We are implementing a standardized, high-efficiency recertification model that accelerates the verification process while simultaneously enforcing strict compliance with all federal docu...
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to a comprehensive transformation of our eligibility lifecycle. We are implementing a standardized, high-efficiency recertification model that accelerates the verification process while simultaneously enforcing strict compliance with all federal documentation requirements and cybersecurity protocols. Action Step: 1. Standardized SOPs & File Uniformity – Implement a mandatory "TANF Case Management Handbook." This SOP mandates a uniform file legend and sequence for all regions, ensuring that evidence for Child Support, IRPs, and school attendance is consistently filed. 2. Revised Recertification Protocol – Revise the recertification workflow to reduce processing times. This includes pre-filling eligibility renewal forms with existing data and automating the flagging of missing documents 30 days prior to the expiration of the 6-month certification period. 3. Mandatory Supervisory Review – Supervisors will approve a verification checklist for every new case and recertification, confirming that all 11 required documents are present before benefit approval. 4. Continuous Training Initiative – Launch a mandatory quarterly training course for all staff on eligibility rules, the 60-month time limit tracking, and the legal consequences of improper benefit issuance. IMPLEMENTATION DATE During Fiscal Year 2026-2027 RESPONSIBLE PERSON Blanca M. Medina Díaz Administrator Gerhil Medina Baez Auxiliary Administrator Operational Services Johana Hernandez Andaluz TANF Program Director
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to a comprehensive transformation of our eligibility lifecycle. We are implementing a standardized, high-efficiency recertification model that accelerates the verification process while simultaneously enforcing strict compliance with all federal docu...
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to a comprehensive transformation of our eligibility lifecycle. We are implementing a standardized, high-efficiency recertification model that accelerates the verification process while simultaneously enforcing strict compliance with all federal documentation requirements and cybersecurity protocols. Action Step: 1. Standardized SOPs & File Uniformity Implement a mandatory "TANF Case Management Handbook." This SOP mandates a uniform file legend and sequence for all regions, ensuring that evidence for Child Support, IRPs, and school attendance is consistently filed. 2. Revised Recertification Protocol Revise the recertification workflow to reduce processing times. This includes pre-filling eligibility renewal forms with existing data and automating the flagging of missing documents 30 days prior to the expiration of the 6-month certification period. 3. Mandatory Supervisory Review Supervisors will approve a verification checklist for every new case and recertification, confirming that all 11 required documents are present before benefit approval. 4. Continuous Training Initiative Launch a mandatory quarterly training for all staff on eligibility rules, the 60-month time limit tracking, and the legal consequences of improper benefit issuance IMPLEMENTATION DATE During Fiscal Year 2026-2027 RESPONSIBLE PERSON Blanca M. Medina Díaz Administrator Gerhil Medina Baez Auxiliary Administrator Operational Services Johana Hernandez Andaluz TANF Program Director
VIEWS OF RESPONSIBLE OFFICIALS During Fiscal Year 2024, started to eliminate the use of Social Security Numbers as primary case identifiers and started to implement a system generated unique internal ID for all participants, strengthening adherence to federal PII safeguarding requirements. Action St...
VIEWS OF RESPONSIBLE OFFICIALS During Fiscal Year 2024, started to eliminate the use of Social Security Numbers as primary case identifiers and started to implement a system generated unique internal ID for all participants, strengthening adherence to federal PII safeguarding requirements. Action Step: 1. Standardized SOP’s – Develop and distribute a mandatory "Eligibility Determination & File Maintenance Manual." This SOP will supersede current regional methods and outline exactly how to document income, verify citizenship, and conduct recertifications. 2. Automated Eligibility Verification – Integrate the Eligibility System with external verification databases (such as income verification sources) to replace reliance on estimates, ensuring all eligibility determinations are based on certified, documented data. 3. Mandatory Supervisory Review – Establish a mandatory "Dual-Control" review process. Before any eligibility determination is finalized, a supervisor must sign off on the completeness of the documentation (e.g., Authorization Release, Citizenship Declaration). 4. Training & Certification – Launch a recurring, mandatory training program for all eligibility technicians and supervisors. Training will cover regulatory compliance (2 CFR §200.303), PII protection, and the correct application of verification methods. IMPLEMENTATION DATE During Fiscal Year 2026-2027 RESPONSIBLE PERSON Blanca M. Medina Díaz Administrator Gerhil Medina Baez Auxiliary Administrator Operational Services Marta Soto Ayala NAP Program Director`
VIEWS OF RESPONSIBLE OFFICIALS The data will be evaluated by the IT department to verify the controls in place at the time the files identified as duplicates were issued. Regarding the issuance, the IT department acknowledges an error in the file transmission, which resulted in the information not b...
VIEWS OF RESPONSIBLE OFFICIALS The data will be evaluated by the IT department to verify the controls in place at the time the files identified as duplicates were issued. Regarding the issuance, the IT department acknowledges an error in the file transmission, which resulted in the information not being matched against the issuance. The data will be available as reference for evaluation. For reconciliation purposes, work will be performed efficiently and within the established timeframes to ensure that all transactions are recorded promptly in the system. This will enable the accurate completion of the reconciliation process, as well as the recording of issuances and any other related transactions, in accordance with established procedures. IMPLEMENTATION DATE During Fiscal Year 2026-2027 RESPONSIBLE PERSON Blanca M. Medina Díaz Administrator Eddie J. Burgos Auxiliary Administrator for Finance and Budget Carlos Martinez Colón Finance Director Vanessa Ayala Gerena Director of Budget Carmen Ramírez IT Director
Management will review reports on a more frequent basis and will to the best of our abilities, schedule recertifications well in advance to advance to ensure recertifications are completed timely. Verterans will now be notified at the 60 day mark in order to retain eligibility.
Management will review reports on a more frequent basis and will to the best of our abilities, schedule recertifications well in advance to advance to ensure recertifications are completed timely. Verterans will now be notified at the 60 day mark in order to retain eligibility.
Mansfield Foundation Corrective Action Plan Summary Reviewed and Approved: Frank Jannuzi, Sara Harriger, Lisa Hosegood May 28, 2026 Action 1: Relevant to single audit finding 2024-001: Use external controller services support to ensure timely submission of Required Federal Financial Reports. Planned...
Mansfield Foundation Corrective Action Plan Summary Reviewed and Approved: Frank Jannuzi, Sara Harriger, Lisa Hosegood May 28, 2026 Action 1: Relevant to single audit finding 2024-001: Use external controller services support to ensure timely submission of Required Federal Financial Reports. Planned Implementation An external accounting/controller firm has been engaged to provide oversight and ensure that all bookkeeping and reporting tasks are completed on time. They report to the Vice President and President and work directly with the Director of Finance. They will provide weekly and monthly monitoring of financial procedures, regular financial reporting to management, and track grant reporting deadlines. This arrangement will continue for the foreseeable future. Responsible Party Outsourced CFO; Director of Finance Target Completion Ongoing Action 2: Relevant to single audit finding 2024-001: Apply an internal tracking system to ensure timely submission of Required Federal Financial Reports. Planned Implementation A reporting calendar will be established and maintained by the Director of Programs, with deadlines flagged 30 days in advance. Automated reminders will be circulated to responsible staff one month, two weeks, and one week prior to each filing deadline Responsible Party Outsourced CFO; Director of Finance, Director of Programs Target Completion Implement within three months Action 3: Relevant to single audit finding 2024-001: Implement a management review system to ensure timely submission of Required Federal Financial Reports. Planned Implementation The Vice President will verify completion of each report prior to submission. The President will receive confirmation that the report was submitted on or before the required deadline. Responsible Party President, Vice President, Director of Finance Target Completion Implement within three months Action 4: Relevant to single audit finding 2024-001: Implement a regular briefing to leadership to ensure compliance and monitor timely submission of Required Federal Financial Reports. Planned Implementation Twice annually, the Director of Finance will brief leadership on the status of required reports and confirm compliance. Responsible Party Outsourced CFO, Director of Finance Target Completion Implement within three months Action 5: Relevant to single audit finding 2024-001: Assign clear lines of responsibility to ensure timely submission of Required Federal Financial Reports. Planned Implementation The President and Vice President are ultimately accountable for submission of timely reports and will provide adequate resources and support, monitor regular bookkeeping and grant deadlines, and hold staff accountable for preparation of the reports. The Directors of Programs and of Finance will be the primary lead for monitoring deadlines, gathering information, and effectuating the timely preparation and submission of all financial reports. Responsible Party President, Vice President, Director of Programs, Director of Finance Target Completion Ongoing Action 6: Develop and formally document a standardized month‑end and year‑end close checklist, including required reconciliations, review sign‑offs, and reporting deadlines. Planned Implementation Management will implement a formal month‑end and year‑end close checklist that outlines key close activities, required account reconciliations, documentation standards, review and approval sign‑offs, and established reporting timelines. The checklist will clearly assign responsibility for each task to designated finance personnel to ensure accountability and consistency in execution. Responsible Party Outsourced CFO; Director of Finance Target Completion Implement for the next fiscal quarter close Action 7: Establish documented review procedures for key balance sheet accounts, including independent review of reconciliations and journal entries. Planned Implementation Management will implement formal, documented review procedures requiring monthly balance sheet reconciliations for all accounts, prepared on a timely basis and reviewed by appropriate Finance lead. In addition, management will require review and approval of journal entries associated with period‑end close activities to strengthen oversight and reduce the risk of error or misclassification. These review procedures will be integrated into the month‑end and year‑end close process and retained as part of the Foundation’s accounting records. Responsible Party Outsourced CFO; Director of Finance Target Completion Ongoing Action 8: Implement a formal budget‑to‑actual review process with documented explanations and periodic reporting to the Board of Directors Planned Implementation Management will establish a standardized budget‑to‑actual review process to be performed on a recurring Quarterly basis. This process will include preparation of variance analyses with documented explanations for significant differences between actual results and the approved budget. These reviews will be completed timely and used as a monitoring control to identify unexpected trends or potential misstatements requiring further review. Responsible Party Outsourced CFO; Director of Finance, Director of Programs Target Completion Implement within three months Action 9: Implement a structured system for tracking grants and contributions, including documentation of donor intent, restriction classification, and release schedules Planned Implementation Management will implement formal grant and contribution tracking procedures designed to document donor and grantor restrictions at the time of receipt and to monitor those restrictions throughout the life of the award. These procedures will support appropriate classification of net assets with and without donor restrictions and timely recognition of releases from restriction in accordance with donor intent and applicable GAAP rules. Responsible Party Outsourced CFO; Director of Finance Target Completion Implement within three months Action 10: Establish procedures for timely identification and release of donor‑restricted funds in accordance with donor and grantor requirements Planned Implementation Management will implement documented procedures to ensure that donor‑imposed restrictions and grantor requirements are identified at the time of receipt and tracked throughout the life of the contribution or grant. These procedures will include quarterly review of restricted net asset balances to ensure that restrictions are released in a timely manner when the applicable purpose or time requirements are satisfied. Responsible Party Outsourced CFO; Director of Finance Target Completion Ongoing Action 11: Strengthen technical accounting review through training, cross‑training, and use of qualified external resources as needed. Planned Implementation To address this recommendation, management has engaged an outsourced accounting team to provide technical accounting support and to assist with the development and documentation of formal finance policies and standard operating procedures (SOPs). These SOPs and policies will establish consistent accounting practices, clarify review and approval responsibilities, and provide appropriate documentation to support accounting judgments and GAAP‑compliant financial reporting. In addition, management will implement targeted training and cross‑training within the finance function to strengthen internal technical accounting knowledge and reduce reliance on single individuals for critical accounting functions. Periodic technical review by qualified internal and external personnel will be incorporated into the close and review process to support accurate application of accounting standards. Responsible Party Outsourced CFO; Director of Finance Target Completion Ongoing Action 12: Improve segregation of duties and compensating controls where full segregation is not feasible Planned Implementation To strengthen segregation of duties within the finance function, management has hired a full‑time Finance Associate, which will allow for clearer separation of transaction processing, review, and reconciliation responsibilities. In addition, management has engaged a part‑time, outsourced accounting firm to provide supplemental support, oversight, and review of selected accounting activities. Responsible Party Vice President, Outsourced CFO; Director of Finance, Finance Assistant Target Completion Within six months Action 13: Continued segregation of duties Planned Implementation Where limited staffing continues to constrain full segregation, management will implement and document compensating controls, including review of reconciliations, journal entries, and financial reports by qualified personnel. Management believes these actions will enhance the design and operating effectiveness of internal controls, reduce reliance on single‑person processes, and support more accurate and reliable financial reporting in accordance with GAAP. Responsible Party Vice President, Outsourced CFO; Director of Finance, Finance Assistant Target Completion Within six months
Schedule of Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-003: Significant Deficiency and Noncompliance over Eligibility Responsible Official’s Response and Corrective Action Plan: We concur with the findings related to deficiencies in Internal Controls and Noncompliance over ...
Schedule of Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-003: Significant Deficiency and Noncompliance over Eligibility Responsible Official’s Response and Corrective Action Plan: We concur with the findings related to deficiencies in Internal Controls and Noncompliance over Eligibility related to our federal grant. In response, BCI has streamlined document collection and tracking and has strengthened its onboarding and document retention procedures to ensure all member files include the required documentation, including the signed member agreements. Planned Implementation Date of Corrective Action Plan September 1, 2024 Person Responsible for Corrective Action Plan Caryn York, President & CEO
Management's Response: AMHE Tenant Occupancy Specialist's will review and adhere to AMHE's Admission and Eligibility Program Management and Occupancy Master Requirements and will attend training courses that will help strengthen their eligibility policy and procedures. Estimated Completion Date: Imm...
Management's Response: AMHE Tenant Occupancy Specialist's will review and adhere to AMHE's Admission and Eligibility Program Management and Occupancy Master Requirements and will attend training courses that will help strengthen their eligibility policy and procedures. Estimated Completion Date: Immediately Interim Director will review the Admission and Eligibility Program Management and Occupancy requirements per AMHE's policy and procedures. This will be addressed with AMHE staff prior to 6/30/26. Responsible Party: Comptroller and Interim Director.
Management acknowledges the need to ensure that required documentation is complete and retained in each tenant file, including executed leases, required forms, inspection documentation, and other required program documents. Corrective actions implemented include the creation and use of a standardize...
Management acknowledges the need to ensure that required documentation is complete and retained in each tenant file, including executed leases, required forms, inspection documentation, and other required program documents. Corrective actions implemented include the creation and use of a standardized eligibility determination checklist that requires documented supervisory sign-off in each tenant file to ensure all required documentation is complete prior to assistance approval. Staff have completed refresher training on timing requirements, documentation standards, and calculation procedures.
Management recognizes the importance of maintaining clear, documented evidence of supervisory review of eligibility determinations, income calculations, and supporting documentation. Corrective actions implemented include the creation and use of a standardized eligibility determination checklist tha...
Management recognizes the importance of maintaining clear, documented evidence of supervisory review of eligibility determinations, income calculations, and supporting documentation. Corrective actions implemented include the creation and use of a standardized eligibility determination checklist that includes supervisory review steps requiring documented supervisory sign-off in each tenant file prior to finalizing eligibility. A standardized tracker is also being used to ensure completeness of the process.
Audit Finding: Late Issuance of the Single Audit Reporting Package. The Single Audit package for the City’s fiscal year ended June 30, 2024 was not submitted to the Federal Audit Clearinghouse by March 31, 2025. Corrective Action: Management agrees with the finding. The City is evaluating the proces...
Audit Finding: Late Issuance of the Single Audit Reporting Package. The Single Audit package for the City’s fiscal year ended June 30, 2024 was not submitted to the Federal Audit Clearinghouse by March 31, 2025. Corrective Action: Management agrees with the finding. The City is evaluating the process and design of internal controls, including the ongoing implementation of a new ERP system, in order to ensure readiness from the audit and to avoid late filing of the single audit reporting package and data collection form. Name of Contact Person and Completion Date: Leah Kagan, Interim Director of Administration, December 31, 2026 Anita Carpenter, Grants Officer, December 31, 2026
Views of Responsible Officials and Planned Corrective Actions: The Finance Department acknowledges the late submission for the 2023 fiscal year. To ensure future compliance with Uniform Guidance deadlines, year-end close and audit preparation timelines have been restructured as per the response for ...
Views of Responsible Officials and Planned Corrective Actions: The Finance Department acknowledges the late submission for the 2023 fiscal year. To ensure future compliance with Uniform Guidance deadlines, year-end close and audit preparation timelines have been restructured as per the response for Finding 2024-001.
Finding 2024 – 101 – Annual Recertification of Income Not Performed, Documentation of Eligibility (Material Weakness, Material Noncompliance) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistanc...
Finding 2024 – 101 – Annual Recertification of Income Not Performed, Documentation of Eligibility (Material Weakness, Material Noncompliance) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD042; AZ20Q081002 Pass-Through grantors: N/A Compliance Requirement: Eligibility Questioned Costs: Unknown Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: 1. Complete all missed annual recertifications immediately. • Method: The property manager shall immediately Identify every tenant file where an annual income recertification was not performed. Collect and verify all required documentation from the affected tenants, using third-party verification as the preferred method. • Responsible Party: Property Manager. 2. Document all eligibility factors and discrepancies. • Method: For every affected tenant file, thoroughly document the process of verifying income, assets, and eligibility. Include explanations for any missing third-party verifications and document all follow-up attempts. • Responsible Party: Property Manager. 3. Retransmit corrected HUD Form 50059 filings to the TRACS system. • Method: Submit corrections for each tenant with a file deficiency by using the "Correction/Retransmittal" (R) code on a new Form HUD-50059A. • Responsible Party: Property Manager. 4. Address any rent-related issues arising from the missing recertifications. • Method: Calculate any potential back-rent owed by tenants due to misreporting or changes in income. Based on HUD guidelines and property policy, negotiate repayment plans if necessary, but carefully follow guidance regarding tenant culpability. • Responsible Party: Property Manager. 5. Revise and formalize resident file management policies and procedures. • Method: Update internal policy and procedural documents to establish clear, step-by-step instructions for completing annual recertifications, including all documentation requirements. Incorporate a standardized checklist for each tenant file to ensure consistent application. • Responsible Party: Controller and Property Manager. 6. Implement an improved tickler and tracking system. • Method: Use property management software to automatically generate alerts and reports for upcoming recertification deadlines. Implement a double-check process where a supervisor reviews and signs off on the list of upcoming deadlines each month to ensure no file is missed. • Responsible Party: Property Manager. 7. Provide comprehensive training for all staff involved in recertifications. • Method: Conduct mandatory training for all staff on Section 811 program requirements, focusing specifically on annual income recertifications and acceptable documentation. Include regular refresher training and create a central, accessible library of HUD guidance. • Responsible Party: Third Party Training Professionals, HUD and Property Manager’s compliance officer. 8. Establish a quality control review process. • Method: Implement a desk review process where a senior staff member or third-party consultant periodically audits a sample of completed recertification files. This internal monitoring should check for accuracy, completeness, and proper documentation. • Responsible Party: Property Manager. 9. Develop a monthly compliance monitoring report. • Method: The report will summarize the status of all recertifications for the month, listing upcoming deadlines and noting any files that required a correction. This will be presented to senior management. • Responsible Party: Property Manager. 10. Conduct a follow-up review. • Method: Engage an external auditor or consultant to perform a follow-up review of recertification files after the first year of the new procedures. This independent assessment will verify that the corrective actions are working effectively. • Responsible Party: Senior Management. 11. Provide status reports to HUD. • Method: As per the notice of noncompliance, submit regular reports to the relevant HUD Hub or Program Center detailing the progress on the CAP and any specific items requested. • Responsible Party: Property Manager and Chief Financial Officer of Sponsor. Anticipated Completion Date: December 2025
Finding 2024 – 101 – Annual Recertification of Income Not Performed, Documentation of Eligibility (Material Weakness, Material Noncompliance) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistanc...
Finding 2024 – 101 – Annual Recertification of Income Not Performed, Documentation of Eligibility (Material Weakness, Material Noncompliance) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD046; AZ20Q09100 Pass-Through grantors: N/A Compliance Requirement: Eligibility Questioned Costs: Unknown Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: 1. Complete all missed annual recertifications immediately. • Method: The property manager shall immediately Identify every tenant file where an annual income recertification was not performed. Collect and verify all required documentation from the affected tenants, using third-party verification as the preferred method. • Responsible Party: Property Manager. 2. Document all eligibility factors and discrepancies. • Method: For every affected tenant file, thoroughly document the process of verifying income, assets, and eligibility. Include explanations for any missing third-party verifications and document all follow-up attempts. • Responsible Party: Property Manager. 3. Retransmit corrected HUD Form 50059 filings to the TRACS system. • Method: Submit corrections for each tenant with a file deficiency by using the "Correction/Retransmittal" (R) code on a new Form HUD-50059A. • Responsible Party: Property Manager. 4. Address any rent-related issues arising from the missing recertifications. • Method: Calculate any potential back-rent owed by tenants due to misreporting or changes in income. Based on HUD guidelines and property policy, negotiate repayment plans if necessary, but carefully follow guidance regarding tenant culpability. • Responsible Party: Property Manager. 5. Revise and formalize resident file management policies and procedures. • Method: Update internal policy and procedural documents to establish clear, step-by-step instructions for completing annual recertifications, including all documentation requirements. Incorporate a standardized checklist for each tenant file to ensure consistent application. • Responsible Party: Controller and Property Manager. 6. Implement an improved tickler and tracking system. • Method: Use property management software to automatically generate alerts and reports for upcoming recertification deadlines. Implement a double-check process where a supervisor reviews and signs off on the list of upcoming deadlines each month to ensure no file is missed. • Responsible Party: Property Manager. 7. Provide comprehensive training for all staff involved in recertifications. • Method: Conduct mandatory training for all staff on Section 811 program requirements, focusing specifically on annual income recertifications and acceptable documentation. Include regular refresher training and create a central, accessible library of HUD guidance. • Responsible Party: Third Party Training Professionals, HUD and Property Manager’s compliance officer. 8. Establish a quality control review process. • Method: Implement a desk review process where a senior staff member or third-party consultant periodically audits a sample of completed recertification files. This internal monitoring should check for accuracy, completeness, and proper documentation. • Responsible Party: Property Manager. 9. Develop a monthly compliance monitoring report. • Method: The report will summarize the status of all recertifications for the month, listing upcoming deadlines and noting any files that required a correction. This will be presented to senior management. • Responsible Party: Property Manager. 10. Conduct a follow-up review. • Method: Engage an external auditor or consultant to perform a follow-up review of recertification files after the first year of the new procedures. This independent assessment will verify that the corrective actions are working effectively. • Responsible Party: Senior Management. 11. Provide status reports to HUD. • Method: As per the notice of noncompliance, submit regular reports to the relevant HUD Hub or Program Center detailing the progress on the CAP and any specific items requested. • Responsible Party: Property Manager and Chief Financial Officer of Sponsor. Anticipated Completion Date: December 2025
Satisfactory Academic Progress Planned Corrective Action: The SAP policy will be reviewed or created as needed and a procedure will be implemented based on that policy. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/...
Satisfactory Academic Progress Planned Corrective Action: The SAP policy will be reviewed or created as needed and a procedure will be implemented based on that policy. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026
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