Corrective Action Plans

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Those charged with governance agreed with the finding and will work to maintain tenant files in accordance with legislation, regulations, and the terms and conditions of the major federal award program.
Those charged with governance agreed with the finding and will work to maintain tenant files in accordance with legislation, regulations, and the terms and conditions of the major federal award program.
Management acknowledges the auditors’ review of HUD HOME eligibility testing. We believe our current processes generally comply with HUD requirements; however, we recognize the opportunity to strengthen controls. To address the auditors’ comments, we will enhance our eligibility verification procedu...
Management acknowledges the auditors’ review of HUD HOME eligibility testing. We believe our current processes generally comply with HUD requirements; however, we recognize the opportunity to strengthen controls. To address the auditors’ comments, we will enhance our eligibility verification procedures, improve documentation consistency, and provide additional staff training. These corrective actions will help ensure ongoing compliance and accuracy in eligibility determinations. Personnel Responsible for Implementation: Meredith Elguira Position of Responsible Personnel: Community Development Director Expected Date of Implementation: April 30, 2026
The Finance and Administration Department will create an internal policy requiring a copy of the SAM.gov search results for the vendor, including the date of the search, and store the documentation in the appropriate grant file. Further, the policy will require a sign-off process where the vendor pa...
The Finance and Administration Department will create an internal policy requiring a copy of the SAM.gov search results for the vendor, including the date of the search, and store the documentation in the appropriate grant file. Further, the policy will require a sign-off process where the vendor payment cannot be finalized without a "Debarment Check Complete". The Finance and Administration Department will include quality control checks and perform regular internal audits of a sample of vendor files related to grants to check for the presence of the Suspension and Debarment Check. Personnel Responsible for Implementation: Meredith Elguira, Carol Molina, Ralston Turner Position of Responsible Personnel: Interim Community Development Director, Finance and Administration Director, Senior Finance Analyst Expected Date of Implementation: April 30, 2026
Management will conduct a comprehensive review of existing processes and internal controls related to eligibility determination and documentation to ensure alignment with federal requirements. As part of this effort, management will evaluate the timing and sequencing of required signatures to better...
Management will conduct a comprehensive review of existing processes and internal controls related to eligibility determination and documentation to ensure alignment with federal requirements. As part of this effort, management will evaluate the timing and sequencing of required signatures to better reflect operational realities while maintaining compliance.
Personnel Responsible For the Corrective Action: Eric Keith, Director of Finance Anticipated Completion Date September 30, 2026 Corrective Action Plan: The vendor has already updated the financial information page to show the Poverty Scale Base Income and Poverty Scale Increment fields so that a use...
Personnel Responsible For the Corrective Action: Eric Keith, Director of Finance Anticipated Completion Date September 30, 2026 Corrective Action Plan: The vendor has already updated the financial information page to show the Poverty Scale Base Income and Poverty Scale Increment fields so that a user could see how the automated percentage of poverty is calculated. Corrective actions include that within 60 days, the Corporation will determine the root cause of the error, and will implement procedures to have a back-up person manually check the poverty scales within the system after they are updated each year by the data specialist and the data specialist will randomly sample cases opened each day for the first two weeks after the update to verify the calculations and then again quarterly after that. Within 90 days, the Corporation will review cases that were actually over 125%, or other appropriate poverty level limits, and determine if there is any financial impact and report any adjustments.
Finding 2025-001 – Eligibility (Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance) Planned Corrective Action: The Seattle Indian Health Board is implementing enhanced corrective actions to ensure full compliance with Indian Health Service eligibility requiremen...
Finding 2025-001 – Eligibility (Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance) Planned Corrective Action: The Seattle Indian Health Board is implementing enhanced corrective actions to ensure full compliance with Indian Health Service eligibility requirements, specifically related to documentation of Tribal enrollment. While prior corrective actions established foundational training and audit processes, management has identified the need for stronger front-end controls, clearer accountability, and system-based safeguards to prevent recurrence. Seattle Indian Health Board will implement the following actions: 1. Strengthen Front-End Eligibility Controls - Eligibility verification protocols will be updated to require complete Tribal enrollment documentation prior to scheduling non-urgent appointments. - A standardized eligibility checklist will be embedded into intake workflows to ensure all required documentation is identified and collected before services are rendered. 2. System Enhancement and Documentation Tracking - Electronic health record workflows will be enhanced to include required fields and alters for missing eligibility documentation, including Tribal enrollment. - Patients with incomplete eligibility records will be flagged, and services will be limited to allowable scenarios until documentation is obtained. 3. Targeted Training and Competency Validation - All registration and front desk staff will undergo mandatory retraining focused specifically on Tribal enrollment documentation requirements and compliance standards. - Staff competency will be validated through post-training assessments and periodic spot checks. 4. Enhanced Monitoring and Internal Audit - Monthly eligibility audits will be expanded to include a statistically valid sample size and documented review of Tribal enrollment verification. - Audit results will be formally reported to executive leadership, with identified deficiencies tracked through resolution. - Repeat errors or noncompliance will be addressed through corrective coaching and performance management, as appropriate. Management believes these enhanced corrective actions directly address the root cause of the finding by strengthening preventive controls, improving staff competency, and increasing oversight and accountability. Name of Responsible Party: Tempest Dawson, Director of Clinic Operations Anticipated Completion Date: December 31, 2026.
The Housing Authority of New Orleans (HANO) acknowledges the deficiencies identified in the audit related to tenant eligibility documentation, Housing Assistance Payment (HAP) calculations, and file accessibility during the transition to digital records. HANO will correct the deficiencies noted in t...
The Housing Authority of New Orleans (HANO) acknowledges the deficiencies identified in the audit related to tenant eligibility documentation, Housing Assistance Payment (HAP) calculations, and file accessibility during the transition to digital records. HANO will correct the deficiencies noted in the sampled files, including completing overdue recertifications, obtaining required HUD forms and identification documentation, securing proper third-party income verification, and recalculating HAP amounts where necessary. The Authority will also conduct an expanded internal review of additional tenant files to determine whether similar issues exist and will correct any deficiencies identified. To prevent recurrence, HANO has initiated formal staff training to reinforce compliance with HUD eligibility requirements, documentation standards, and proper HAP calculation procedures. Training began on March 19, 2026, and is being conducted by Circular Consulting LLC, a thirdparty firm with expertise in Housing Choice Voucher program compliance and operations. This training will continue through September 2026 to ensure staff receive comprehensive instruction and reinforcement of HUD program requirements. In addition, HANO will strengthen internal controls by implementing additional quality control (QC) reviews of tenant files and recertifications, including supervisory review of eligibility documentation and HAP calculations to ensure accuracy and completeness. These enhanced QC monitoring procedures will begin on April 20, 2026, and will be conducted on an ongoing basis to ensure errors are identified and corrected promptly. The Authority will also reconcile physical and digital tenant records to ensure that all files are properly digitized, complete, and accessible following the transition to electronic records. Responsible Party: Sonja Young, Director Implementation Timeline: Start Date: March 30, 2026 Completion Date: May 18, 2026
Recommendation: We recommend the SNP reviews its internal controls and policies to ensure all students receiving benefits have an application, or other supporting documentation, on file to support their eligibility. Action taken in response to finding: Management acknowledges the finding and will re...
Recommendation: We recommend the SNP reviews its internal controls and policies to ensure all students receiving benefits have an application, or other supporting documentation, on file to support their eligibility. Action taken in response to finding: Management acknowledges the finding and will revise and formalize internal controls as follows: • Eligibility Documentation Procedures: Develop a standardized checklist to confirm required documentation is obtained, reviewed and retained prior to approval. • Centralize Review and Approval Process: A designated reviewer will be responsible for verifying completeness and accuracy of all eligibility determinations. Approval will be formally documented. • Record Retention Controls: Management will establish controls to ensure that all eligibility documentation is: Properly maintained, readily accessible for audit or review and retained in accordance with federal, state and organization-wide policy. • Personnel Training: Training will be conducted annually and upon onboarding new personnel. Name of the contact person responsible for corrective action: Sean Jernigan, Chief of Operational Vitality, Department of Catholic Schools, Archdiocese of Los Angeles Planned completion date for corrective action plan: • Procedure and checklist implementation: Within 30 days of financial statement issuance • Staff training: Within 60 days of financial statement issuance • Full implementation and evidence of operation: 90 days of financial statement issuance
Management will implement procedures to ensure timely submission of all required federal reports by establishing a centralized grants compliance calendar with automated deadline reminders, assigning both primary and backup personnel responsible for report preparation and submission, and requiring su...
Management will implement procedures to ensure timely submission of all required federal reports by establishing a centralized grants compliance calendar with automated deadline reminders, assigning both primary and backup personnel responsible for report preparation and submission, and requiring supervisory review and approval prior to filing. Management will monitor reporting deadlines monthly to ensure compliance.
Pine Tree holds biannual mandatory staff trainings on the LSC regulations, which include a review of the requirements for retainers and citizenship attestations. In the summer of 2025, the trainings consisted of a series of short videos that are now saved to our Training Library and available to new...
Pine Tree holds biannual mandatory staff trainings on the LSC regulations, which include a review of the requirements for retainers and citizenship attestations. In the summer of 2025, the trainings consisted of a series of short videos that are now saved to our Training Library and available to new staff. We have processes in place to obtain the required documents on paper or electronically. We are currently in the process of finalizing a new DocAssemble process that will make it easier for staff to obtain electronic retainers. Pine Tree continues to prioritize compliance with these rules. We will continue to work on policies and procedures, and stay up to date on technological advances, that can help us overcome the factors that lead to occasions in which clients do not return the documents that Pine Tree provided for their review and completion. These factors can include the time-sensitive nature of our work, clients’ inability to meet in person, the large geographic size of our service area, and some clients’ significant mental health issues that limit their capacity to complete paperwork. We will continue to evaluate the barriers, and systematic solutions to reduce these barriers. The anticipated completion date for this corrective action is September 1, 2026. Local office trainings are being scheduled for May and June which will include reminders about these requirements. The new electronic retainer process should be finalized by the end of August. The other
Oversight Agency for Audit, Senior Citizens Housing Development Corporation of South Boston, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive,...
Oversight Agency for Audit, Senior Citizens Housing Development Corporation of South Boston, Inc. respectfully submits the following corrective action plan for the year ended December 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: January 1, 2025 through December 31, 2025 The findings from the December 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2025-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure that all initial and ongoing tenant eligibility documentation is obtained timely and maintained in tenant files as required by HUD. 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.
In order to avoid recurrence of such errors in future years, LSNC is implementing a checklist for integrity reports (a draft of which is attached to this memo) and a mid-year programwide integrity report process to identify and correct errors. The checklist of integrity reports will be used and reta...
In order to avoid recurrence of such errors in future years, LSNC is implementing a checklist for integrity reports (a draft of which is attached to this memo) and a mid-year programwide integrity report process to identify and correct errors. The checklist of integrity reports will be used and retained by the executive assistant and the interim executive director to verify that all necessary reports are run and reviewed twice each year. A copy of each report will be retained with the checklist as an additional verification measure. The mid-year review will occur in June or July and will include income and asset eligibility checks on closed cases - using a report of all closed cases that shows the household composition, asset amount and the LSC eligibility selection for each case. The interim executive director and the executive assistant responsible for programwide integrity reports will both review the report and examine any cases that exceed the asset limit for the case household size. Ineligible cases will be corrected to indicate they are not LSC-eligible, meaning that they will not be reported. If LSC funds were used to support the case, those time entries will be changed to charge appropriate funds and staff will prepare revised timesheets. The same review will be repeated at the end of the calendar year, before case data is reported to LSC (and prior to the self-inspection process). This additional review should further strengthen the processes already in place. This process is not time limited. It will be added to LSNC's regular compliance activities. If you have any questions or concerns about LSNC's proposed plan, please contact me at (916) 551-2179 or via email at jaguilar@lsnc.net.
Finding #2025-001 Comments on the Finding and Each Recommendation: During the year ended September 30, 2025, three of the thirteen resident files selected for testing under the OMB Compliance Supplement lacked properly executed and documented resident eligibility forms. WHN Property Management shoul...
Finding #2025-001 Comments on the Finding and Each Recommendation: During the year ended September 30, 2025, three of the thirteen resident files selected for testing under the OMB Compliance Supplement lacked properly executed and documented resident eligibility forms. WHN Property Management should complete recertifications for the two residents still residing at the Property, ensure that all resident files are maintained at the site for each resident of the Property, and ensure that the resident files include all properly executed and documented resident eligibility forms. Action(s) taken or planned on the finding: WHN Property Management concurs with the finding and recommendation. WHN Property Management is in the process of completing recertifications for two of the residents still residing at the Property. One of the resident files noted in the statement of condition was for a resident who moved out of the Property in November 2025. No further action is required related to this resident's file. WHN Property Management intends to review and update, as necessary, the other resident files during the year ended September 30, 2026 to ensure the Property is in compliance with the OMB Compliance Supplement and the HOME loan agreement.
Recommendation: We recommend that management implement a control to ensure complete documentation is maintained for all cases that require retainer agreement. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: Legal Aid Ch...
Recommendation: We recommend that management implement a control to ensure complete documentation is maintained for all cases that require retainer agreement. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: Legal Aid Chicago's Deputy Director/General Counsel has already contacted the employees who made the errors with respect to missing retainers and has included their supervisors in the communication to ensure compliance on a forward-looking basis. The Deputy Director/General Counsel will also hold a compliance training for staff covering LSC regulations by the end of Q3 2026. Name of the contact person responsible for corrective action: Teresa Sullivan, Deputy Director / General Counsel Planned completion date for corrective action plan: September 30, 2026
Recommendation: We recommend that management implement a control to review PAI time entries to ensure they are accurate. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: While issues with PAI time for non-case activity w...
Recommendation: We recommend that management implement a control to review PAI time entries to ensure they are accurate. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: While issues with PAI time for non-case activity were successfully remediated with the implementation of a required drop-down activity description field in the LegalServer case management system, the two erroneous entries in 2025 involved case time and resulted from cases that were opened as PAI “Yes” due to the intake occurring at a volunteer clinic and the expectation of volunteer attorney involvement that did not ultimately occur. Legal Aid Chicago's Deputy Director/General Counsel has already contacted the employees who made the errors with respect to PAI time and has included their supervisors in the communication to ensure compliance on a forward-looking basis. The Deputy Director/General Counsel will also hold a compliance training for staff covering LSC regulations by the end of Q3 2026. Name of the contact person responsible for corrective action: Teresa Sullivan, Deputy Director / General Counsel Planned completion date for corrective action plan: September 30, 2026
Corrective Action: The Center will: - Provide immediate re-training to staff on issues identified, and - Continue to provide ongoing training to current and new staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and bi...
Corrective Action: The Center will: - Provide immediate re-training to staff on issues identified, and - Continue to provide ongoing training to current and new staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing, and - Have updated procedures for the Sliding Fee Discount Program approval process in which all sliding fee required documents are reviewed and approved by a Clinic Manager or his/her designee for program compliance within 3-5 business days. Revise SFDP application form to add the space where Clinic Manager or designee can document the reviewed by and date of approval, and - Continue ongoing SFDP Chart Audits to assess compliance with policy and guidelines, staff knowledge, and provide feedback, as needed.
FINDING 2025-003: Title I Eligibility Response: To ensure all records are correctly filed and maintained, the district is establishing new protocols for documenting Title eligibility.
FINDING 2025-003: Title I Eligibility Response: To ensure all records are correctly filed and maintained, the district is establishing new protocols for documenting Title eligibility.
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a tra...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing certifications on time and in accordance with applicable regulations. Ownership periodically reviews the agent's procedures to ensure that they complete tenant files on time and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a tra...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing certifications on time and in accordance with applicable regulations. Ownership periodically reviews the agents' procedures to ensure that they complete tenant files on time and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson , Chief Financial and Operating Officer.
Corrective Action: The Organization agrees with the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party managers as of January 1, 2026. These agents have a track record of completing, documenting, and retaining certifications in acco...
Corrective Action: The Organization agrees with the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party managers as of January 1, 2026. These agents have a track record of completing, documenting, and retaining certifications in accordance with applicable regulations. Ownership periodically reviews the agents' procedures to ensure that they document and maintain tenant files in accordance with HUD and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a tra...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing certifications on time and in accordance with applicable regulations. Ownership periodically reviews the agents' procedures to ensure that they complete tenant files on time and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson , Chief Financial and Operating Officer.
Corrective Action: The Organization agrees with the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing, documenting, and retaining certification...
Corrective Action: The Organization agrees with the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing, documenting, and retaining certifications in accordance with applicable regulations. Ownership periodically reviews the agents' procedures to ensure that they document and maintain tenant files in accordance with HUD and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a tra...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing certifications on time and in accordance with applicable regulations. Ownership periodically reviews the agent's procedures to ensure that they complete tenant files on time and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Finding: 2025-084 - The University did not properly maintain documentation to demonstrate a student’s intent to become a permanent resident. Questioned Costs: None Assistance Listing Number: 84.044 Assistance Listing Title: TRIO Cluster Views of Responsible Officials (state whether your agency agree...
Finding: 2025-084 - The University did not properly maintain documentation to demonstrate a student’s intent to become a permanent resident. Questioned Costs: None Assistance Listing Number: 84.044 Assistance Listing Title: TRIO Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): There is no disagreement with the audit finding. Corrective Action (corrective action planned): Services for the students involved have been terminated. UAA has reviewed the current procedures and implemented system improvements to prevent similar omissions in the future. The existing student eligibility verification checklist has been reviewed thoroughly to ensure all required documentation is in place; and a random sample of students files will be reviewed semi-annually to proactively identify any issues. In addition, all the staff involved have completed the necessary training. Completion Date (list anticipated completion date): Completed Agency Contact (name of person responsible for corrective action): Tamika Dowdy, UAA TRIO Programs Director, 907-786-4520
Finding: 2025-081 - During inquiries with management the University of Alaska identified multiple students during enrollment verification process that they determined were fictious. Questioned Costs: AL 84.007: 4,947, AL 84.063: 27,059, AL 84.268: 158,554 Assistance Listing Number: 84.063 84.268 84....
Finding: 2025-081 - During inquiries with management the University of Alaska identified multiple students during enrollment verification process that they determined were fictious. Questioned Costs: AL 84.007: 4,947, AL 84.063: 27,059, AL 84.268: 158,554 Assistance Listing Number: 84.063 84.268 84.007, 84.033 Assistance Listing Title: Student Financial Assistance Cluster (SFAC) Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): There is no disagreement with the audit finding. Corrective Action (corrective action planned): The university has been actively implementing process improvements across all campuses (UAF, UAA and UAS) to strengthen controls and prevent similar occurrences. Enhancements to the existing processes include the deployment of multilayered interim screening measures to mitigate fraudulent accounts and strengthen internal controls. In addition, the University has acquired a long-term software solution which is currently in the final phase of implementation, to further enhance identity verification procedures and strengthen cybersecurity capabilities. Completion Date (list anticipated completion date): May 31, 2026 Agency Contact (name of person responsible for corrective action): Amanda Wall, AVC, UAF Financial Services, 907-474-7552
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