Corrective Action Plans

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Address weaknesses in eligibility verification and waiting list management: 1. Policy Review: Review and verify that the Admissions and Continued Occupancy Policy (ACOP) clearly states the requirement that all admissions originate from the approved waiting list and what documentation is required to ...
Address weaknesses in eligibility verification and waiting list management: 1. Policy Review: Review and verify that the Admissions and Continued Occupancy Policy (ACOP) clearly states the requirement that all admissions originate from the approved waiting list and what documentation is required to be in the participate file as waitlist verification 2. Staff Training: Provide refresher training for Public Housing staff on eligibility verification and waiting list procedures. Require dual staff sign-off on all new admissions to confirm eligibility and waiting list documentation before lease execution. 3. Waiting List Audit: Conduct a semi-annual audit of waiting list transactions to ensure documentation accuracy and selection order compliance. 4. Software Updates: Review and select a new software to assist with income item collection. Software should allow residents to upload and store documentation. This will allow greater transparency as the residents and staff will view the same information. In addition, all information would be date and time stamped to ensure tasks were completed in a timely manner.
Corrective Action: The Public Housing Authority (PHA) will strengthen eligibility determination procedures for the Housing Choice Voucher Program by implementing the following measures: 1. Policy Reinforcement: Review and update, if necessary, the Administrative Plan to explicitly outline required e...
Corrective Action: The Public Housing Authority (PHA) will strengthen eligibility determination procedures for the Housing Choice Voucher Program by implementing the following measures: 1. Policy Reinforcement: Review and update, if necessary, the Administrative Plan to explicitly outline required eligibility documentation and verification steps. 2. Staff Training: Conduct training sessions for HCV Specialists on verifying income, assets, and household composition. Staff to begin using HUD’s CPD calculator to calculate income. 3. Quality Control Review: Implement a quarterly supervisory review, by the Housing Manager, of a random 10% sample of tenant files to ensure accuracy in income calculation and documentation. 4. File Checklist: Implement file checklists in each file to ensure all items are collected correctly and available for compliance review. 5. Software Updates: Review and select a new software to assist with income item collection. Also implement the use of DocuSign to obtain signatures.
Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Los Angeles respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201,...
Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Los Angeles respectfully submits the following corrective action plan for the year ended June 30, 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: July 1, 2024 through June 30, 2025 The finding from the June 30, 2025 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned 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 initial and ongoing tenant eligibility documentation is obtained timely and properly maintained. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and tenant file maintenance and included in monthly report procedures. If the Oversight Agency for Audit has questions regarding these plans, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips CFO
Corrective Action Plan December 18, 2025 Massachusetts Department of Elementary and Secondary Education Office of Charter Schools and School Redesign 135 Santilli Highway Everett, MA 02149 Lawrence Family Development Charter School respectfully submits the following corrective action plan for the ye...
Corrective Action Plan December 18, 2025 Massachusetts Department of Elementary and Secondary Education Office of Charter Schools and School Redesign 135 Santilli Highway Everett, MA 02149 Lawrence Family Development Charter School respectfully submits the following corrective action plan for the year ended June 30, 2025: AAF CPAS 50 Washington Street Westborough, MA 01581 Audit period: July 1, 2024 to June 30, 2025 (Fiscal Year 2025) The findings from the December 22nd schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - FINANCIAL STATEMENT AUDIT FINDINGS SIGNIFICANT DEFICIENCY 2025-01 Massachusetts Teachers' Retirement Board (MTRB) Remittances Regulations outlined in DESE's Charter School Audit Guide require Massachusetts Teachers' Retirement System (MTRS) payroll withholdings to be remitted to the MTRB within ten days of the following month. During our compliance testing, we noted nine instances, out of twelve months tested, for which the MTRS payroll withholdings were not remitted to the MTRB within ten days of the following month. Recommendation: In order to comply with Commonwealth of Massachusetts' MTRB regulations and charter school compliance requirements established by DESE, management should ensure that controls are in place to ensure all MTRS payroll withholdings are remitted timely. Action Taken: We concur with the recommendation, and LFDCS has implemented a policy requiring all MTRS payments to be completed within the first ten calendar days of each month. Effective Date: December 1, 2025 SIGNIFICANT DEFICIENCY 2025-02 Payroll Records The Federal government requires Form I-9's be maintained for all eligible employees. Out of the twenty-five selections tested, we noted one 1-9 form which was not properly completed by the School. We also noted four additional selections where the 1-9 form was unable to be located. We also noted there was no supporting documentation maintained for two W-4 forms. The School experienced turnover in the accounting and finance department during fiscal year 2025. Review of required document was not performed on a timely basis. Because of the failure to maintain required forms, ineligible employees may be added to payroll. Recommendation: Procedures should be implemented requiring the completion of required forms and the formal review and approval should be performed prior to adding employees to payroll. Action Taken: We concur with the recommendation, and LFDCS has implemented procedures to review personnel files for completeness and accuracy before new employees begin working at the school. Effective Date: December 1, 2025 2025-03 General Ledger Maintenance During fiscal year 2025, several general ledger accounts were not properly reconciled to their respective subsidiary ledgers, journals, or supporting schedules. In certain instances, reconciliations were prepared; however, variances were not clearly identified, investigated, or resolved. In other cases, reconciliations were performed in an untimely manner. The accounts affected included revenue and the related Federal expenditures, cash, accounts receivable, accounts payable, and due from Lawrence Prospera (the Fund). Unreconciled variances were also noted in various expense and accrued expense balances. Recommendation: Management should implement policies and procedures to ensure that all general ledger accounts are reconciled to the respective subsidiary ledgers, journals, or supporting schedules on a timely basis. Any variances identified during the reconciliation process should be promptly investigated and resolved to maintain the accuracy and reliability of the financial statements and ensure compliance with Federal grant reporting requirements. Implementing these procedures will strengthen internal controls, help prevent potential misstatements in the financial statements, and facilitate a smoother and more efficient audit process. Action In-Process: We concur with the auditor's recommendation. The LFDCS is in the process of implementing an accounting system while also developing accounting policies that set comprehensive standards and procedures to ensure the integrity and accuracy of the General Ledger (GL). The completed policy will include internal controls to safeguard financial data, prevent errors, and reduce the risk of fraud. It will also require segregation of duties by defining distinct roles for authorization, data entry, and review so that no individual is responsible for both recording transactions and reconciling accounts. These measures will provide accurate verification of assets and liabilities through monthly balance sheet account reconciliations and will enable timely and reliable financial reporting and budget-to-actual variation analysis. Anticipated Effective Date: March 1, 2026 2025-04 Bank Reconciliations During the fiscal year 2025 audit, we noted that the School's operating bank account reconciliations had not been prepared for several months after month end and did not agree to the reconciled bank balance. As a result, a large year-end adjustment was required before the audit to record previously unrecorded transactions in the general ledger. When bank reconciliations are not performed consistently and in a timely manner, there is an increased risk of unauthorized transactions or bank errors going undetected. Management should prepare bank reconciliations immediately upon receipt of the monthly bank statement, further, any outstanding checks which have not cleared within a reasonable time should be investigated upon completion of the monthly reconciliation. Recommendation: There is a lack of segregation of duties as it relates to the bank reconciliation process. The same employee who prepares the bank reconciliations also records the related journal entries in the general ledger. In addition, we did not observe evidence of management review or approval of the bank reconciliations prior to recording activity in the accounting records. This lack of segregation of duties increases the risk of errors or potentially resulting in misstatements of cash balances or unauthorized transactions. Action In-Process: We concur with the auditor's recommendation. Once the accounting system implementation is complete, LFDCS will adopt a reconciliation policy that ensures all cash transactions are properly recorded, complete, and any differences are resolved within ten days of the bank statement closing date. High-volume accounts will be reconciled weekly or more frequently as needed. To maintain sufficient segregation of duties, the Finance Team will prepare the reconciliations while the Director of Finance or another designated approver review and approve them. Under no circumstances will the same person prepare and approve the reconciliation. Additionally, the School will set up an integration between its bank and QuickBooks Online so that bank-cleared transactions are automatically downloaded, reducing manual data entry and increasing the efficiency and accuracy of the reconciliation process. Any discrepancies identified during the process will be investigated and corrected within ten days of month-end, and all reconciliations will be securely saved and readily available. Anticipated Effective Date: March 1, 2026 MATERIAL INSTANCE OF NONCOMPLIANCE 2025-05 Certified Procurement Officer Regulations outlined in the Massachusetts Department of Elementary and Secondary Education's (DESE) Charter School Audit Guide require a charter school administrator who serves as procurement officer to have a valid Massachusetts Certified Public Purchasing Official (MCPPO) designation. During fiscal year 2025, we noted that the School does not have any administrator who has MCPPO designation. Recommendation: In order to comply with DESE's procurement requirements, management should ensure that proper controls are in place and operating effectively to ensure that a designated individual has enrolled and receives a valid MCPPO designation. Management should also develop a checklist that tracks expiration date for MCPPO eligible employees to ensure timely renewal. Action In-Process: We concur with the auditor's recommendation. LFDCS acknowledges the requirement outlined in the Massachusetts Department of Elementary and Secondary Education's (DESE) Charter School Audit Guide that a charter school administrator serving as the procurement officer must hold a valid Massachusetts Certified Public Purchasing Official (MCPPO) designation. To comply with this requirement, the directors of facilities and finance in addition to the grant accountant will enroll in the MCPPO certification program offered by the Massachusetts Office of the Inspector General and ensure they complete the training if not certification process. LFDCS will also implement internal controls to track MCPPO certification status and expiration dates to ensure compliance and timely renewal. The Finance Director completed the initial course, Public Contracting Overview, on December 17th, 2025. Anticipated Effective Date: May 1, 2026 If the Department of Education and Secondary Education has questions regarding LFDCS's plans, please call Mark Ventre, Director of Finance, at 978.216.0461, extension 185. Sincerely yours, Signature : Mark Ventre Email: mventre@lfdcs.org Mark Ventre Director of Finance Lawrence Family Development Charter School
Name of Contact Person: Tonya Vannasdall, Director. Recommendation: We recommend that the Council perform a file review on all recipients to ensure that documentation of eligibility is retained. Secondarily, we recommend that Council strengthen its procedures to ensure that all required eligibility ...
Name of Contact Person: Tonya Vannasdall, Director. Recommendation: We recommend that the Council perform a file review on all recipients to ensure that documentation of eligibility is retained. Secondarily, we recommend that Council strengthen its procedures to ensure that all required eligibility documentation is obtained and retained prior to authorizing program participation and charging costs to the federal award. Corrective Action: The Executive Director will implement a file review process and a process to ensure each file contains documentation of eligibility. Proposed Completion Date: Immediately.
Recommendation #1: We recommend the District develop a system to review the maintenance of effort )MOE) calculations with all supporting documentation before submitting it to NYSED. Response: The District accepts this finding and has trained the new staff members on implementing this recommendation ...
Recommendation #1: We recommend the District develop a system to review the maintenance of effort )MOE) calculations with all supporting documentation before submitting it to NYSED. Response: The District accepts this finding and has trained the new staff members on implementing this recommendation to gather the Maintenance of Effort (MOE) calculations. Anticipated Completion Date: March 2026 Person Responsible for Corrective Action Plan: Jerel Cokley - Asst. Supt. For Business
Finding 2025-002: Eligibility Responsible Individuals: Kari Williams, Chief Financial Officer Corrective Action Plan: The Organization reviewed the attendance form and made changes so it is easier to read. The Organization will review reimbursement requests and watch for errors. Anticipated Completi...
Finding 2025-002: Eligibility Responsible Individuals: Kari Williams, Chief Financial Officer Corrective Action Plan: The Organization reviewed the attendance form and made changes so it is easier to read. The Organization will review reimbursement requests and watch for errors. Anticipated Completion Date: December 31, 2025
The County will complete a quarterly review of errors in income and documentation. For those staff identified by the targeted review with errors in these areas, supervisors will provide refresher training on Medicaid policy requirements. Additional targeted reviews will be completed monthly until th...
The County will complete a quarterly review of errors in income and documentation. For those staff identified by the targeted review with errors in these areas, supervisors will provide refresher training on Medicaid policy requirements. Additional targeted reviews will be completed monthly until the deficiencies are corrected.
Management has set up training to address all issues regarding the wait list and how to go about selecting those off the waitlist. This training will take place in January of 2026 And it will help those on site to have a full understanding of what is needed when it comes to our wait list.
Management has set up training to address all issues regarding the wait list and how to go about selecting those off the waitlist. This training will take place in January of 2026 And it will help those on site to have a full understanding of what is needed when it comes to our wait list.
Management have put together a recertification team that will oversee our recertifications and we will bring staff on site in to train going forward in the future This will help to ensure that all documents are signed all consent forms there will also be training that deals with tenant selection on ...
Management have put together a recertification team that will oversee our recertifications and we will bring staff on site in to train going forward in the future This will help to ensure that all documents are signed all consent forms there will also be training that deals with tenant selection on the wait list as well as training with maintaining tenant files.
2025-001 Federal Work Study - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2025 Condition Found During our Federal Work Study testing, we selected twenty-five students and noted that one student was paid for hours they did...
2025-001 Federal Work Study - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2025 Condition Found During our Federal Work Study testing, we selected twenty-five students and noted that one student was paid for hours they did not work and was overpaid $420. The College did not review federal work study hours worked against class hours scheduled and timesheets to ensure the student was not working during a scheduled class and that they were paid for the correct number of hours. We consider this condition to be an instance of non-compliance to the Eligibility compliance requirement. Corrective Action Plan The Financial Aid Department is collaborating with Career Services to implement improved oversight and training for Federal Work-Study. This includes required online training for both student employees and their supervisors, which must be completed prior to hiring any student employees within a department. Additionally, a campus-wide Standard Operating Procedure (SOP) has been developed, along with a Quick Guide for Supervisors of Student Employees, to ensure consistent processes and expectations related to scheduling, timesheet review, and compliance. Responsible Person for Corrective Action Plan Program Manager — Student Employment/Veteran Affairs Director of Career Services and Job Placement Implementation Date of Corrective Action Plan 08/22/2025
Title and AL Number of Federal Program: 14.181 Supportive Housing for Persons with Disabilities (Section 811) Federal Award Agency: U.S. Department of Housing and Urban Development Name of Contact Person: Barry Gault, Chief Financial Officer Corrective Action: 1) Management will assign a secondary r...
Title and AL Number of Federal Program: 14.181 Supportive Housing for Persons with Disabilities (Section 811) Federal Award Agency: U.S. Department of Housing and Urban Development Name of Contact Person: Barry Gault, Chief Financial Officer Corrective Action: 1) Management will assign a secondary review by the Compliance Manager and establish controls in place to ensure that recertifications are performed timely. Date of Planned Corrective Action: 09/15/2025 Submitted by: Barry Gault
Title and AL Number of Federal Program: 14.181 Supportive Housing for Persons with Disabilities (Section 811) Federal Award Agency: U.S. Department of Housing and Urban Development Name of Contact Person: Barry Gault, Chief Financial Officer Corrective Action: 1) Management will assign a secondary r...
Title and AL Number of Federal Program: 14.181 Supportive Housing for Persons with Disabilities (Section 811) Federal Award Agency: U.S. Department of Housing and Urban Development Name of Contact Person: Barry Gault, Chief Financial Officer Corrective Action: 1) Management will assign a secondary review by the Compliance Manager and establish controls in place to ensure that recertifications are performed timely. Date of Planned Corrective Action: 09/15/2025 Submitted by: Barry Gault
2025-001: Missing Exit Counseling Documentation Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, 84.379 Grant Period – Year Ended June 30, 2025 Condition Found Condition/Context: During our student file testing, we noted two students out of forty did not have d...
2025-001: Missing Exit Counseling Documentation Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, 84.379 Grant Period – Year Ended June 30, 2025 Condition Found Condition/Context: During our student file testing, we noted two students out of forty did not have documentation in their file that exit counseling was sent thirty days after the student withdrew. We consider the missing exit counseling to be an instance of noncompliance with the Eligibility Compliance Requirement. Corrective Action Plan Concordia has created new reporting and updated its Exit Counseling policy to put any students without concurrent semester enrollment, excluding traditional undergraduates who are not required to take summer, into "EXIT". Responsible person for corrective action plan: Kevin Sheridan Implementation Date of Corrective Action Plan: December 11, 2025
2025-001 Significant Deficiency: Awards in Excess of Aggregate Limits (U.S. Department of Education, William D. Ford Direct Loan Program, ALN #84.268) The University awarded and disbursed Federal Direct Loans beyond aggregate limits. Management Response Management concurs with the auditors’ finding....
2025-001 Significant Deficiency: Awards in Excess of Aggregate Limits (U.S. Department of Education, William D. Ford Direct Loan Program, ALN #84.268) The University awarded and disbursed Federal Direct Loans beyond aggregate limits. Management Response Management concurs with the auditors’ finding. Due to delays and changes in the National Student Loan Data System (NSLDS) post-screening process for the 2024–25 award year, Federal Direct Loans were inadvertently awarded and disbursed to students who had previously exceeded Federal Direct Loan aggregate limits. Responsible Person(s) Alex Campbell, Director of Financial Aid, and Kaitrin Parrett, Assistant Director of Financial Aid, are designated as the individuals responsible for implementing the corrective action. Corrective Action Plan Upon identifying deficiencies in loan aggregate reporting and over-award status, the Financial Aid Office initiated communication with the identified students to inform them of their overaward status and the process for resolving inadvertent overborrowing. In collaboration with software engineers, the Financial Aid Office is developing updated reporting to ensure proper identification of students who are ineligible due to meeting or exceeding aggregate limits set by the U.S. Department of Education. The Financial Aid Office tested and reviewed NSLDS post-screen data and student loan aggregates prior to the disbursement of Fall 2025 Federal Direct Loans to ensure students were not awarded or disbursed aid for which they were ineligible. Reviews of NSLDS post-screen data confirm that the Student Information System (SIS) accurately identifies student aggregate borrowing flags. The Financial Aid Office is also monitoring designated mailboxes to ensure any additional NSLDS post-screen data is reviewed and aggregate limits on student accounts are updated accordingly. All financial aid staff involved in awarding federal loans completed additional training on NSLDS review requirements, aggregate limit monitoring, and reaffirmation procedures prior to Fall 2025 disbursements. Training will continue on a quarterly basis to ensure proper procedures are followed by Financial Aid staff. Compliance reviews will be conducted on a semester basis to ensure that Title IV aid is not awarded to students in excess of their annual or aggregate limits. The Director and Assistant Director of Financial Aid will review aggregate limit reports monthly as part of the University’s internal operational calendar. Expected Completion Date This corrective action plan was implemented in September 2025, prior to Fall 2025 aid disbursements, which began on September 12, 2025.
Incorrect Resolution of ISIR Aggregate Limits Flag Planned Corrective Action: All financial aid staff received a copy of the FAFSA Specifications Guide, Volume 7 – Comment Codes applicable to the current academic year, and are required to reference this guide for each student file they review to ens...
Incorrect Resolution of ISIR Aggregate Limits Flag Planned Corrective Action: All financial aid staff received a copy of the FAFSA Specifications Guide, Volume 7 – Comment Codes applicable to the current academic year, and are required to reference this guide for each student file they review to ensure that all comment codes requiring resolution are properly addressed. Additionally, the Assistant Director of Financial Aid distributes daily ISIR import reports to all financial aid staff. Any ISIRs requiring resolution are identified within these reports as well as within the corresponding student files in our system. To address the system limitations identified, the University has acquired a new Software-as-a-Service (SaaS) financial aid management system. Person Responsible for Corrective Action Plan: Executive Director of Financial Aid, Robert Hamilton, and Assistant Director of Compliance & Reporting, Brooke Tyler, and Assistant Director of Financial Aid, Alyssa Shealor Anticipated Date of Completion: June 30, 2026
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: WBU has entered into an agreement with Ellucian to implement Ellucian Student powered by Colleague as the new student information system. WBU will start utilizing this new student information syste...
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: WBU has entered into an agreement with Ellucian to implement Ellucian Student powered by Colleague as the new student information system. WBU will start utilizing this new student information system in April 2026. WBU will utilize the built-in functionality and tools to report to NSLDS at that time which should correct this issue completely. We will continue to work towards compliance with NSLDS reporting requirements through the following action plan: An internal SSRS report for official and unofficial withdrawals which accurately reflects withdrawn students remains available to the WBU offices of Financial Aid and the Registrar for verification as part of the planned corrective action. The custom NSC reporting tool(s) will continue to be updated to make sure the correct combination of fields and corresponding data sources are reported as accurately as possible. WBU will continue to work with NSC to mitigate issues related to data not transferring correctly between NSC and NSLDS. • A field-by-field analysis plus any needed corrections to the queries will be performed. o By default, term "W" withdrawals are reconsidered by the updated tool each time a report is generated for NSC. o Some date fields have been corrected that were previously misunderstood by the custom tool's historical authors. o Post-submission error corrections by registrar staff via NSC's website are spot-checked by Information Technology when requested. o If certain data issues cannot be resolved satisfactorily via NSC alone, then corrective measures via NSLDS directly may be considered. o The PowerCampus 9.1.2 baseline product's NSC reporting tool was determined to be insufficient for timely and accurate reporting to NSC with WBU's current data on several counts. WBU has upgraded the PowerCampus system to version 9.2.3 and will continue to work towards a solution for the baseline reporting tool with the upgraded system.  Some of the recurring data updates needed before running the PC baseline tool, are still being run periodically as a source data benefit for the custom tool. Person Responsible for Corrective Action Plan: Chief Information Officer, Cagan Cummings Anticipated Date of Completion: Ongoing
Management's Response: We concur. Views of Responsible Officials and Corrective Action Plan Response: The two students identified were underpaid due to locks on their financial aid units for either late-start courses or being on an approved SAP appeal plan. Once locks were removed, PowerFAIDS should...
Management's Response: We concur. Views of Responsible Officials and Corrective Action Plan Response: The two students identified were underpaid due to locks on their financial aid units for either late-start courses or being on an approved SAP appeal plan. Once locks were removed, PowerFAIDS should have recalculated their aid to reflect their current units, however that did not happen. As a result, the Pell Grant was under-awarded. The students have now been disbursed with their full Pell eligibility. Corrective Action Plan: The transition from a legacy SIS and PowerFAIDS to a single ERP will consolidate financial aid and enrollment data into a single system, eliminating reliance on manual adjustments and reducing the risk of data discrepancies between two systems. Banner allows for automated and real-time recalculations for enrollment changes such as late start courses, reducing the risk of Pell under or over-awarding. Financial aid staff will receive updated training and guidance on the importance of verifying Pell recalculations when manual locks on student financial aid records are needed, for instance in the case of a student on an approved SAP appeal plan.
Section III Federal Award Findings and Questioned Costs Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care),) Grants for New and Expanded Services Under the Health Center Program, COVID-19 Grants for New and Expanded...
Section III Federal Award Findings and Questioned Costs Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care),) Grants for New and Expanded Services Under the Health Center Program, COVID-19 Grants for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2025 002 – Special Tests Recommendation The Center should establish a system of internal controls to ensure that all slide fee discounts are properly calculated based on family size and income. Repeat Finding Yes Action Taken The Finance Department will take the following steps to enhance the slide fee discounts process: 1. Policy Revision: the health center will revise its Sliding Fee Discount Policy to ensure alignment with HRSA requirements, including accurate discount calculation methodologies, annual updates to the sliding fee scale, and proper utilization of NextGen system functionality to support implementation 2. Staff Training: the health center will provide comprehensive training to all relevant staff on the revised Sliding Fee Discount Policy and procedures. 3. Training will emphasize correct discount calculations, required documentation, and income verification processes. A recurring training program will be implemented to ensure ongoing compliance for both new hires and existing employees. 3. Retrospective Review: the health center will conduct a retrospective review of patient files for the current fiscal year to confirm that all sliding fee discounts are appropriately supported by required documentation. Any identified discrepancies will be corrected in a timely manner. 4. Ongoing Monitoring: the health center will establish monthly internal audits of sliding fee discount determinations to monitor compliance. Audit results will be documented and reviewed by management to ensure corrective actions are taken as needed. Responsible Party: Chief Financial Officer Target Completion Date: 04/30/2026 If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Javier Vallejo, CFO at (314)-482-0915. Sincerely yours, Javier Vallejo Chief Financial Officer
FINDING No. 2025-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure that all required tenant eligibility steps are performed in accordance with HUD regulations, utilize the EIV system for income verification, inspect unit...
FINDING No. 2025-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure that all required tenant eligibility steps are performed in accordance with HUD regulations, utilize the EIV system for income verification, inspect units timely, and maintain all supporting documentation in the tenant files. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and tenant file maintenance and included in monthly reporting procedures. If the Oversight Agency for Audit has questions regarding this plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips CFO
Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Chicago respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Cor...
Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Chicago respectfully submits the following corrective action plan for the year ended June 30, 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: July 1, 2024 through June 30, 2025 The finding for the June 30, 2025 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. SECTION III – FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2025-001: Project Based Rental Assistance Program, ALN 14.195 Recommendation: The Project should implement procedures to ensure that proper initial eligibility procedures are conducted for potential tenants and that tenant files are accurately maintained. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and tenant file maintenance and included in monthly reporting procedures. If the Oversight Agency for Audit has questions regarding this plan, please call Irene Phillips at 954- 835-9200. Sincerely yours, Irene Phillips, CFO Irene Phillips CFO
Condition: The District could not find 1 free/reduced application selected. Recommendation: We recommend establishing a procedure to ensure that all applications are kept in a manner where they can be found in the future. Management Response: The district has employed a new Food Service Director. Th...
Condition: The District could not find 1 free/reduced application selected. Recommendation: We recommend establishing a procedure to ensure that all applications are kept in a manner where they can be found in the future. Management Response: The district has employed a new Food Service Director. The new Director has been made aware of the previous errors and is following the procedures to double check applications and organize and store documents in a manner in which they can be retrieved with the appropriate back up for food claims. Anticipated Date of Completion: June 30, 2026
Condition: Based upon single audit testing noted 4 applications approved in the wrong category: two applications that were approved as free but should have been reduced, one application that was approved reduced but should have been free, and one application that was approved reduced but should have...
Condition: Based upon single audit testing noted 4 applications approved in the wrong category: two applications that were approved as free but should have been reduced, one application that was approved reduced but should have been free, and one application that was approved reduced but should have been paid. Also noted that per ISBE exam, ISBE noted eight applications that were approved in the wrong category: 7 applications that were approved free but should have been reduced and one application that was approved free but should have been paid. Also, the ISBE exam noted two applications that were missing a valid SNAP case number. Recommendation: We recommend establishing a procedure to ensure household eligibility applications are approved in the appropriate category according the current income guidelines. Management Response: All household eligibility applications will be first taken be one employee, checked over by a second employee and then confirmed by a third employee. Anticipated Date of Completion: June 30, 2026
Management Response: The Public Assistance and Employment Services (PAES) Division of Fairfax County Department of Family Services (DFS) acknowledges the audit finding regarding Medicaid renewals. These late renewals are attributed to the timing and cadence of Medicaid Unwinding requirements post pa...
Management Response: The Public Assistance and Employment Services (PAES) Division of Fairfax County Department of Family Services (DFS) acknowledges the audit finding regarding Medicaid renewals. These late renewals are attributed to the timing and cadence of Medicaid Unwinding requirements post pandemic. From March 2020 to March 2023, a federal waiver was issued, pausing annual renewal processes for Medicaid eligibility. During this time, changes in household financial circumstances, which rendered prior enrollee’s ineligible under traditional Medicaid criteria, were not in effect. When redetermination resumed these cases were deemed ineligible at the appropriate time, consistent with federal policy. PAES prepared for the resumption of suspended Medicaid renewals beginning in January 2023. An internal Medicaid Unwinding Steering and Implementation Committee (MUSIC) was created to oversee the reinstatement of the redetermination process and analyze the strategy for achieving redetermination of suspended renewal cases. In April 2023, PAES began the redetermination process for suspended Medicaid renewals in addition to reviewing new applications. The County faced a backlog of more than 54,000 suspended cases alongside 125,000 current active Medicaid cases for rolling renewals during the unwinding period. During this time, PAES instituted several operational strategies to manage backlogs and new cases by prioritizing a portion of suspended renewals each month, collaborating with the Virginia Department of Social Services (VDSS), providing training and IT tools for monitoring case statuses, and holding monthly progress tracking sessions. By February 2024, the County had processed 32,000 suspended renewals (62%), and by the end of May 2024, completion reached 97% of all suspended cases. During FY 2025, the number of current renewals continued to be impacted by the redirection of resources to move through the suspended pandemic-related renewals. As a result, PAES established an Overdue Medicaid Renewal Project to take action on approximately 8,000 current renewals. This effort resulted in an 80% reduction in the number of overdue renewals. As of December 2025, PAES has restructured teams with a unit dedicated to ongoing Medicaid-only renewals for more efficient work and in preparation for new legislation. The County has successfully managed its workload and ensured compliance even under exceptional challenges and policy waivers imposed by federal agencies during the pandemic. The County maintains robust processes to ensure the future timeliness of Medicaid renewals while adhering to state and federal requirements. Currently, the timeliness of Medicaid renewals is 97.7 %. The strategic measures outlined above will continue to improve our overall compliance in FY 2026.
First Place Response - The management team continues to address this issue in a multi-faceted approach. First Place for Youth has already taken substantial steps to address the issue, including retraining County Program Managers, expanding the scope of internal audits and automating checklist tracki...
First Place Response - The management team continues to address this issue in a multi-faceted approach. First Place for Youth has already taken substantial steps to address the issue, including retraining County Program Managers, expanding the scope of internal audits and automating checklist tracking within the case management system. First Place for Youth would like to emphasize that the audit did not identify any instances where an ineligible participant entered into the program. The organization will continue to refine these processes to ensure timely and complete supervisory review going forward including: • Revising the File Audit and Maintenance Policies and Procedures • Incorporating process management protocols including more efficient digital certification procedures • Ongoing training of staff on the process • Tracking staff noncompliance and elevating issue to management and/or senior leadership
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