Corrective Action Plans

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MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount...
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount. Financial counselors have 7 business days from the return of a patient application to determine completeness and eligibity for sliding fee scale. The Chief Financial Officer, Kara Onorato, will be responsible for ensuring that this process is followed. The new policy was approved by the board of Directors in December 2025. The new process is being implemented in 2026. Internal audit began monthly audits and corrective training in February 2026 with target goal by Q3 2026.
Corrective Action Plan – Single Audit Finding Entity Name: Brocton Housing Development Company, Inc. Audit Period: For the year Ended September 30, 2025 Finding Reference Number: 14.157 Federal Program: Supportive Housing for the Elderly (Section 202) 1. Audit Finding Summary Describe the audit find...
Corrective Action Plan – Single Audit Finding Entity Name: Brocton Housing Development Company, Inc. Audit Period: For the year Ended September 30, 2025 Finding Reference Number: 14.157 Federal Program: Supportive Housing for the Elderly (Section 202) 1. Audit Finding Summary Describe the audit finding and the specific noncompliance identified by the auditor. In accordance with 24 CFR 891.400(e), a separate interest-bearing project fund account shall be maintained in a depository or depositories which are members of the Federal Deposit Insurance Corporation or National Credit Union Share Insurance Fund and all tenant payments, charges, income and revenues arising from project operation or ownership shall be deposited to this account. 2. Root Cause Explain the underlying reasons for the finding, such as process gaps, training issues, or lack of controls. Subsequent to the initial rental assistance contract, changes to HUD regulations resulted in the requirement that the project fund account be an interest-bearing account. This change was an oversight by the Company's management. 3. Corrective Actions Action Item: Use an interest-bearing account for project funds Responsible Person: Chief Financial Officer Completion Date: TBD Status: In process 4. Monitoring Plan Describe how the implementation of corrective actions will be monitored and evaluated. Management inquired with the bank and deemed the cost outweighs the benefit due to the fees charged for an interest bearing account exceeding the interest that would be earned. 5. Contact Information Name: Aaron Hejmowski Title: Chief Financial Officer Phone: 716-884-7791 Email: ahejmowski@belmonthousingwny.org
Assistance Listing 14.239 – HOME Investment Partnership Program Material Weakness in Internal Control over Compliance; Material Noncompliance – Eligibility Background of Occurrence: For the year under audit, not all tenant income re-certifications were found in paper or digital form in the company f...
Assistance Listing 14.239 – HOME Investment Partnership Program Material Weakness in Internal Control over Compliance; Material Noncompliance – Eligibility Background of Occurrence: For the year under audit, not all tenant income re-certifications were found in paper or digital form in the company files after the termination of the former property manager in February, 2026. Planned Corrective Action: To address this issue prospectively, WCCAC has implemented an internal system to ensure re-certifications are completed timely, with three levels of accountability as outlined in the new Homes Program Internal Control Compliance Memo (see attached) Under Paragraph “Control Activities” it outlines new corrective action procedures to ensure compliance. Anticipated Completion Date: April, 2026 – This corrective action has been incorporated immediately into our internal processes. Name and Title of Contact Person Responsible for Corrective Action: Timothy Fisher, Chief Executive Officer
Assistance Listing 14.239 – HOME Investment Partnership Program Material Weakness in Internal Control over Compliance; Material Noncompliance – Special Tests and Provisions – Housing Quality Standards Background of Occurrence: For the year under audit, the historically maintained consolidated inspec...
Assistance Listing 14.239 – HOME Investment Partnership Program Material Weakness in Internal Control over Compliance; Material Noncompliance – Special Tests and Provisions – Housing Quality Standards Background of Occurrence: For the year under audit, the historically maintained consolidated inspection log that was used to track unit inspections and other supporting documentation was not found in paper or digital form in the company files after the termination of the former property manager in February, 2026. Planned Corrective Action: A new inspection log has been created and fully implemented into the processes to document each unit, the date of inspection, and the condition or quality of the unit. This log is now maintained as part of standard operating procedures and will support timely retrieval of inspection records going forward. We have updated our internal control document related to the Home Investment Partnership with new property staff and review procedures. (see attached) Anticipated Completion Date: April, 2026 – This corrective action has been incorporated immediately into our internal processes. Name and Title of Contact Person Responsible for Corrective Action: Timothy Fisher, Chief Executive Officer
Views of Responsible Officials and Planned Corrective Action: Management is aware of this matter and acknowledges the need to strengthen controls over the timely reconciliation and review of aged accounts payable related to federal awards. Management has implemented, or will implement, enhanced proc...
Views of Responsible Officials and Planned Corrective Action: Management is aware of this matter and acknowledges the need to strengthen controls over the timely reconciliation and review of aged accounts payable related to federal awards. Management has implemented, or will implement, enhanced procedures designed to prevent similar issues in future reporting periods, including: (1) formalizing written policies requiring monthly accounts payable reconciliations; (2) adding a review control focused specifically on items outstanding more than 90 days, including documented investigation and resolution; and (3) training accounting personnel on these procedures and related documentation requirements. Management believes these corrective actions will improve the timely identification, review, and resolution of aged accounts payable balances in future reporting periods.
Community Mental Health Services of Livingston County Single Audit Report: Corrective Action Plan Year ended September 30, 2025 Finding 2025-001- Suspension and Debarment Requirement: As required by 2 CFR 200.214, Non-Federal entities are subject to the non-procurement debarment and suspension regul...
Community Mental Health Services of Livingston County Single Audit Report: Corrective Action Plan Year ended September 30, 2025 Finding 2025-001- Suspension and Debarment Requirement: As required by 2 CFR 200.214, Non-Federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. Condition: The vendor used for this grant was not checked for suspension and debarment prior to execution of the contract. Also, the contract did not include certification that vendor was not suspended or debarred. Questioned Cost: None. Recommendation: We recommend that the CMHSP update contract language to include certification that vendor is not suspended or debarred. Corrective Action Plan LCCMHA will address the concern raised by RPC and agrees with the above recommendation. The Accounting Manager and Associate Director of Finance and Contracts will work with the Contract Manager to modify existing contract language to include certification that vendors are not suspended or debarred. This change will be implemented for fiscal year 2027 commencing 10/01/26. Responsible Party: Jim Kubus, Accounting Manager Anticipated completion date: September 30, 2026
Finding 2025-003: Special Tests and Provisions: NSLDS Reporting Recommendation: The College should develop and implement a formal process for monitoring and updating students' enrollment status in the NSLDS to ensure compliance with reporting requirements. Establish internal controls to track change...
Finding 2025-003: Special Tests and Provisions: NSLDS Reporting Recommendation: The College should develop and implement a formal process for monitoring and updating students' enrollment status in the NSLDS to ensure compliance with reporting requirements. Establish internal controls to track changes in enrollment status and ensure timely updates to the NSLDS. Conduct periodic reviews of the enrollment reporting process to identify and address any inaccuracies or delays. Provide training to relevant staff on the importance of compliance with enrollment reporting requirements and the procedures for accurate and timely updates. Response: The College concurs with Finding 2025-003 and the auditors’ recommendation. To address this finding, the College has implemented the following actions. Corrective Action Responsible Party Target Date Status Execute formal written agreement between FAO and OARR defining data ownership for each NSLDS record type, update timelines, escalation procedures, and monthly reconciliation responsibilities. Agreement reviewed annually. FAO Director/Registrar/VPEMSS 30 days Draft in progress Implement NSLDS Reporting Calendar aligned to the academic calendar, distributed to FAO, Registrar, and VPEMSS. Built-in reminders at 30, 14, and 7 days before each deadline. FAO Director 30 days Being initiated Implement monthly SIS-to-NSLDS reconciliation. The Financial Aid Office (FAO) will reconcile Student Information System (SIS) data against the NSLDS roster, and any discrepancies will be resolved within five (5) business days. Exception reports will be reviewed and certified monthly by VPEMSS. The monthly reconciliation process will be completed before certification by the VPEMSS, and all identified reporting discrepancies will either be corrected or formally documented with an action plan before certification. FAO Director/Registrar 30 days First cycle underway Coordinate with OARR to verify and maintain accurate CIP codes and credential level data for all active programs at start of each academic year. FAO Director/Registrar 60 days In progress Recruit and fill vacant FAO positions to restore NSLDS processing and monitoring capacity. FAO Director/VPEMSS/HRO 90 days In progress Incorporate NSLDS reporting compliance into annual Title IV self-assessment each August. FAO Director/VPEMSS August 2026 Scheduled Primary Responsible Office: Director, Financial Aid Office Oversight Office: Vice President for Enrollment Management and Student Services Overall CAP Completion Target: Within 90 days of the final audit report issuance; NSLDS record updates within 15 days
Finding 2025-002: Special Tests and Provisions: Verification Recommendation: The College should enhance training programs for staff involved in the verification process to ensure they are fully aware of the requirements and procedures. Establish robust internal controls and review mechanisms to ensu...
Finding 2025-002: Special Tests and Provisions: Verification Recommendation: The College should enhance training programs for staff involved in the verification process to ensure they are fully aware of the requirements and procedures. Establish robust internal controls and review mechanisms to ensure that verification worksheets are completed accurately and consistently with ISIRs. Implement a tracking system to ensure that all required corrections to ISIRs are performed in a timely manner. Response: The College concurs with Finding 2025-002 and the auditors’ recommendation. To address this finding, the College has implemented the following actions. Action Responsible Party Target Date Status Reinstate mandatory two-tiered verification file review. No student file in any Verification Tracking Group may be finalized or disbursed without independent review and sign-off by the second FAO staff member. Review logs maintained and submitted monthly to FAO Director. FAO Director/VPEMSS 30 days In progress Implement ISIR Correction Tracking Log. Log captures: date discrepancy identified, date submitted to CPS, CPS confirmation number, and date corrected transaction received. FAO Director reviews weekly. This control directly addresses the gap that led to missed corrections in AY 2024-2025. FAO Director/Student Services Specialist IV 45 days In development Establish mid-year ISIR correction deadline. An internal institutional deadline – set 60 days before the award year closes – will be established to ensure all pending ISIR corrections are submitted before the CPS window closes. FAO Director responsible for tracking FAO Director 30 days Policy and procedure being drafted Mandatory annual FSA verification training for all FAO staff, covering tracking group identification, ISIR-worksheet cross-matching, CPS correction procedures, and the importance of submitting corrections before year-end closure. FAO Director 60 days Scheduled Conduct monthly internal file audits of verified student files. Results reported in writing to the VPEMSS. Shift from quarterly to monthly frequency to ensure errors are caught well before the award year closes. FAO Director 30 days First cycle initiated Revise and redistribute Verification SOP to all FAO staff across all campuses with mandatory sign-off. SOP to include explicit section on ISIR correction deadlines relative to award year closes. FAO Director 30 days In progress Recruit and fill three vacant FAO positions to restore full review capacity FAO Director/VPEMSS/HRO 90 days Recruitment initiated Primary Responsible Office: Director, Financial Aid Office Oversight Office: Vice President for Enrollment Management and Student Services Overall CAP Completion Target: Within 90 days of the final audit issuance
The Health System will take the following actions to resolve the noted conditions: 1. To address the noted conditions for user access reviews the Health System will update SOPs and documentation in two separate areas: a. Vendors/Consultants that do work for the Health System will be instructed to on...
The Health System will take the following actions to resolve the noted conditions: 1. To address the noted conditions for user access reviews the Health System will update SOPs and documentation in two separate areas: a. Vendors/Consultants that do work for the Health System will be instructed to only move changes to production with explicit written approval from the business leader of the Human Resources (HR) function or Human Resources Information Systems (HRIS) leadership. Verbal approval in meetings will be insufficient. The updated requirement will be communicated to all business leads in HR. b. Workday Releases are currently reviewed and tested by HRIS prior to implementation. During testing, the auditors noted two releases that did not have documentation of testing. The two releases relate to modules or functionality not used by the Health System. HRIS will update its practice of reviewing Workday releases to include documentation on release items that do not apply to the Health System and, therefore, do not require testing. This change will be incorporated in HRIS’s SOP and communicated to the team conducting the Workday release reviews. 2. HRIS leadership will update its SOP for UAR to require screenshot of the system generated report used for the UAR and require an HR VP to review the Sr. Manager’s (primary individual doing review) access. The HRIS team will be trained on the updates to the new SOP. 3. We have done a comprehensive review of our implementers/vendors and began disabling them from our systems when they no longer require access to our systems upon completion of services. HR business leads will be required to request implementor/vendor access disablement on the completion of their work. The HR business leads will be trained on this process. As a new additional control, implementers/vendors will be reviewed by HRIS on an annual basis mirroring the current security review process for other users. Person Responsible: Karen Alvarado – Senior Manager HRIS E-mail address: Karen.Alvarado@bmc.org
Planned Corrective Action: When required, the District will enter into an contract to have a single audit completed by the required due date. Anticipated Completion Date: June 30, 2027 Responsible Contact Person: Cliff Angle, Superintendent
Planned Corrective Action: When required, the District will enter into an contract to have a single audit completed by the required due date. Anticipated Completion Date: June 30, 2027 Responsible Contact Person: Cliff Angle, Superintendent
There were interfund transfers from the Mainstream Voucher program to the Business Activities (a nonfederal program), during the fiscal year in the amount of $24,570.
There were interfund transfers from the Mainstream Voucher program to the Business Activities (a nonfederal program), during the fiscal year in the amount of $24,570.
(1) Comments on the Finding and Each Recommendation. Management concurs with the finding and the auditor’s recommendation that interfund transfers should not be made to nonfederal programs from a federal program. In addition, a reconciliation of the Inter Program accounts should be performed on a mo...
(1) Comments on the Finding and Each Recommendation. Management concurs with the finding and the auditor’s recommendation that interfund transfers should not be made to nonfederal programs from a federal program. In addition, a reconciliation of the Inter Program accounts should be performed on a monthly basis and interfund borrowings should be reimbursed within a reasonable timeframe, during the operating cycle.
(2) Actions Taken on the Finding.
(2) Actions Taken on the Finding.
Knox MHA employed a fee accountant to assist in preparing the Hinkle report, assistance with GASB entries, footnotes and REAC submission. It was an oversight of Management and not caught until brought to our attention by the auditor. Had I been aware of this at the time I would have made the correct...
Knox MHA employed a fee accountant to assist in preparing the Hinkle report, assistance with GASB entries, footnotes and REAC submission. It was an oversight of Management and not caught until brought to our attention by the auditor. Had I been aware of this at the time I would have made the correction as I know this is not permitted nor an entry that should be made.
(3) Estimated Completion Date.
(3) Estimated Completion Date.
Discussions have been had with the fee accountant to provide more detailed reviews and further discussions prior to submissions. This is NOT a typical entry nor one I would have approved. This will be corrected by June 30, 2026 to ensure that this does not occur in future audits. I also plan to expl...
Discussions have been had with the fee accountant to provide more detailed reviews and further discussions prior to submissions. This is NOT a typical entry nor one I would have approved. This will be corrected by June 30, 2026 to ensure that this does not occur in future audits. I also plan to explore other options for future submissions.
Finding Reference Number: SA2025-001 Late Submission of FDS (Significant Deficiency) Contact Person: Raul Marquez, Accounting Supervisor Corrective Action Plan: Management will establish timelines and interim milestones for completion of the City’s Annual Comprehensive Financial Report (ACFR) that s...
Finding Reference Number: SA2025-001 Late Submission of FDS (Significant Deficiency) Contact Person: Raul Marquez, Accounting Supervisor Corrective Action Plan: Management will establish timelines and interim milestones for completion of the City’s Annual Comprehensive Financial Report (ACFR) that support timely completion and submission of the City’s audited FDS by the 3/31 deadline. Anticipated Completion Date: June 30, 2026
Moving forward, the Chamber will use an employee’s timesheet to bill wages to federal awards. When preparing reimbursement requests, the staff will calculate the wage amount that is equal to the number of hours each employee self-attested to working to the federal grant by coding the hours on their ...
Moving forward, the Chamber will use an employee’s timesheet to bill wages to federal awards. When preparing reimbursement requests, the staff will calculate the wage amount that is equal to the number of hours each employee self-attested to working to the federal grant by coding the hours on their timesheet for the applicable pay periods. If a true-up of wage expenses is done at any time during the cycle of the federal grant, the Chamber will maintain adequate documentation (the employee timesheets) to indicate how the true-up was calculated. The calculation provided by the staff will be reviewed by the Executive Director prior to the reimbursement request being submitted to the granting agency.
All grants are to be labeled as federal and non-federal when entered into the Chamber’s general ledger (Emily), and when grant documents are saved internally (Chamber Staff). Expenses associated with federal grants are to be coded and classed to those grants for accurate entry on the SEFA (Emily). T...
All grants are to be labeled as federal and non-federal when entered into the Chamber’s general ledger (Emily), and when grant documents are saved internally (Chamber Staff). Expenses associated with federal grants are to be coded and classed to those grants for accurate entry on the SEFA (Emily). The Executive Director (Tom) will be involved in the preparation of the SEFA to ensure only federal grant expenses are included, and that no expenses are omitted.
Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongo...
Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongoing
The Cutter Morning Star is deeply disappointed by the findings identified through the audit and review involving the former superintendent. The State Board determined that violations occurred involving district, state, and/or federal policies and laws, including failure to honestly report enrollment...
The Cutter Morning Star is deeply disappointed by the findings identified through the audit and review involving the former superintendent. The State Board determined that violations occurred involving district, state, and/or federal policies and laws, including failure to honestly report enrollment, misuse of public funds, and misuse of school property. These actions do not reflect the values, expectations, or standards of the district. The findings exposed the district to unnecessary risk and damaged the trust that the community places in its school leadership. The district remains committed to operating with integrity, transparency, accountability, and full compliance with all applicable laws and policies moving forward.
Finding – 2025-001 Reporting – Material Weakness in Internal controls over compliance, Material Non-Compliance Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Year(s): 2025 Federal Agency: US Department of Treasury Corrective Action: Divi...
Finding – 2025-001 Reporting – Material Weakness in Internal controls over compliance, Material Non-Compliance Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Year(s): 2025 Federal Agency: US Department of Treasury Corrective Action: Division will continue to enforce the policy where every grant is sent to the Finance Department for review/approval before the report is submitted to the granting agency(ies). This action will be facilitated and enforced by the Divisional Accounting Manager/Compliance Director. 1. Internal process to be continued throughout FY 2026. 2. The program directors will save a copy of all reporting to the regional internal digital file storage system, as well as send a copy of the finance department for review/approval/storage for audit purposes and the finance department will lastly make sure it is filled out and fulfills the requirement of the contract, as a last line of grant requirement fulfillment. 3. Continued training of field staff and program directors to occur. Anticipated Completion Date: 10/01/2026 Responsible Contact Person: Kendall Phillips, Grants & Contracts Accountant
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Control Procedures • Verify costs fall within grant period prior to posting Review Controls • Require supervisory approval Monitoring • Quarterly compliance testing
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Control Procedures • Verify costs fall within grant period prior to posting Review Controls • Require supervisory approval Monitoring • Quarterly compliance testing
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Cost Allocation Plan • Implement formal allocation plan using drivers such as square footage and headcount Documentation • Maintain invoices, allocation worksheets, and supporting ...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Cost Allocation Plan • Implement formal allocation plan using drivers such as square footage and headcount Documentation • Maintain invoices, allocation worksheets, and supporting schedules Reconciliation • Perform quarterly true-ups between budget and actual Training • Train staff on allocation methodology and documentation Monitoring • Conduct periodic reviews and report results to management
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