Corrective Action Plans

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Disaster Grants - Public Assistance (Presidentially Declared Disasters) – Assistance Listing No. 97.036 Recommendation: We recommend the County establish and implement formal procedures requiring supervisory review and approval of all reports submitted to grantors. Evidence of review should be docum...
Disaster Grants - Public Assistance (Presidentially Declared Disasters) – Assistance Listing No. 97.036 Recommendation: We recommend the County establish and implement formal procedures requiring supervisory review and approval of all reports submitted to grantors. Evidence of review should be documented and retained, including the reviewer’s signature or electronic approval, the date of review, and the date of submission, to support compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has established a review and approval process for quarterly reports. Reports will be reviewed and signed by a member of management to ensure accuracy and completeness of the data being submitted. Name of the contact person responsible for corrective action: Tanya Cannady, Business Services Director Planned completion date for corrective action plan: June 2026
Disaster Grants - Public Assistance (Presidentially Declared Disasters) – Assistance Listing No. 97.036 Recommendation: We recommend the County implement a formal review and reconciliation process to ensure that employees' hours reported on Activity Logs are verified against the reimbursement reques...
Disaster Grants - Public Assistance (Presidentially Declared Disasters) – Assistance Listing No. 97.036 Recommendation: We recommend the County implement a formal review and reconciliation process to ensure that employees' hours reported on Activity Logs are verified against the reimbursement request prior to submitting it to the grantor. This review should be performed by personnel knowledgeable of the grant requirements and documented to evidence the review was completed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will establish a process to maintain effective internal controls to ensure that the documentation is complete and accurately reflected in the reimbursement requests. An internal review and reconciliation process for employee activity logs will be performed prior to submitting to the grantor. Name of the contact person responsible for corrective action: Tanya Cannady, Business Services Director Planned completion date for corrective action plan: June 2026
Veterans’ Health Foundation Corrective Action Plan Federal Drawdown Internal Control Finding 2025-001 Management agrees with the finding. The identified exceptions resulted from inconsistent retention of documented review evidence during a period of transition in finance personnel. While drawdown re...
Veterans’ Health Foundation Corrective Action Plan Federal Drawdown Internal Control Finding 2025-001 Management agrees with the finding. The identified exceptions resulted from inconsistent retention of documented review evidence during a period of transition in finance personnel. While drawdown requests were supported by allowable expenditures and subject to financial oversight, documentation evidencing the control was not consistently maintained for certain transactions. To strengthen internal controls over federal drawdown requests and ensure continued compliance with 2 CFR 200.303, the Veterans Health Foundation will revise and formalize its drawdown procedures as follows: 1. Federal drawdown requests will be prepared by designated finance personnel and supported by appropriate expenditure documentation. 2. The Controller will review supporting documentation and authorize all federal drawdown requests prior to submission to ensure the accuracy, allowability, and appropriateness of reimbursement requests. 3. The CEO will perform and document a monthly reconciliation review of drawdown activity and related expenditures as an additional oversight and monitoring control. 4. The Foundation will update its formal policies and procedures within 60 days to reflect the revised drawdown preparation, review, authorization, reconciliation, and documentation retention requirements. 5. The Foundation is strengthening its document storage and records retention processes to ensure supporting documentation for drawdowns and other federal award activities is consistently maintained, centrally stored, and readily accessible for audit and compliance purposes. 6. As part of the Foundation’s broader administrative modernization initiative, the Foundation is implementing a new cloud-based file storage and records management system during the current fiscal year to improve document retention, access controls, continuity of operations, and long-term compliance oversight. 7. Management has communicated the revised control procedures to finance personnel and will monitor compliance with the updated process. The Foundation believes these corrective actions adequately address the finding and strengthen internal controls over federal cash management activities and records retention. Responsible Officials: Controller and Chief Executive Officer Anticipated Completion Date: Policy updates will be completed within 60 days. All other corrective actions have been implemented effective immediately, with the new cloud-based file storage system to be implemented during the current fiscal year.
DWIGHT WAY HOUSING INC 2220 OXFORD STREET BERKELEY, CALIFORNIA 94704 (510) 841-4410 CORRECTIVE ACTION PLAN March 31, 2026 Cognizant or Oversight Agency for Audit: Department of Housing and Urban Development Dwight Way Housing, Inc. respectfully submits the following corrective action plan for the ye...
DWIGHT WAY HOUSING INC 2220 OXFORD STREET BERKELEY, CALIFORNIA 94704 (510) 841-4410 CORRECTIVE ACTION PLAN March 31, 2026 Cognizant or Oversight Agency for Audit: Department of Housing and Urban Development Dwight Way Housing, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Lindquist von Husen & Joyce LLP 301 Howard Street, Suite 850 San Francisco, CA 94105 Audit period: July 1, 2024, to June 30, 2025 The findings from the June 30, 2025, 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 None noted. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS 2025-001 Compliance over Eligibility Requirements to Perform Annual Recertification - Assistance Listing No. 14.181. Program –Supportive Housing for Persons with Disabilities Significant Deficiency Dwight Way should develop an operating plan in order to ensure that recertifications are performed timely each year, despite of staff shortages. Action Taken: Unanticipated staff shortages created gaps in performance of annual recertifications at this location. New staff has since been hired in the Regional Manager role and the Director role. Both new employees are providing greater oversight and visiting the property regularly to track progress. In addition to our permanent staffing efforts, we have deployed a Property Operations Specialist to bring recertifications current at Dwight Way. This specialist is focused specifically on compliance tasks and critical deadlines. Additionally, senior leadership at the John Stewart Company has implemented enhanced tracking of recertifications across the full portfolio and now conducts monthly progress meetings with management team to monitor compliance, identify risks early, and ensure accountability. We are confident that these corrective actions will result in sustained improvement and ongoing compliance. If the Department of Housing and Urban Development has questions regarding this plan, please call Zelda Ryan, Corporate Controller, at (510) 841-4410 x304#. Sincerely, Eric Knecht, CFO Resources for Community Development
Corrective actions were delayed due to the anticipated implementation of a new system that ws expected to address access and segregation of duties concerns. Since the new system will not be imiplemented immediately, management is proceeding with corrective action under the current system. Management...
Corrective actions were delayed due to the anticipated implementation of a new system that ws expected to address access and segregation of duties concerns. Since the new system will not be imiplemented immediately, management is proceeding with corrective action under the current system. Management is working to define and separate HR and Payroll rolls and access responsibilities so that employee information, pay rates, and payroll related functions are restricted to authorized personnel based on job duties. In the interim, periodic reviews of employee information, user access, and payroll related transactions will be performed. Any unauthorized changes will be documented and retained.
Management concurs with the recommendation and will review the policies and procedures surrounding sliding fee write-offs. In addition, management plans to implement changes to the system where write-offs are automatically calculated and applied. Management plans on providing additional training to ...
Management concurs with the recommendation and will review the policies and procedures surrounding sliding fee write-offs. In addition, management plans to implement changes to the system where write-offs are automatically calculated and applied. Management plans on providing additional training to staff and performing periodic reviews of sliding fee write-offs to ensure compliance with the policies and procedures.
Corrective Action Plan: The organization has implemented targeted training, revised patient intake forms to include standardized income calculations, and established monthly audits for 2026 to ensure compliance with Sliding Fee Discount Program requirements. Clinics identified with a 10% or greater ...
Corrective Action Plan: The organization has implemented targeted training, revised patient intake forms to include standardized income calculations, and established monthly audits for 2026 to ensure compliance with Sliding Fee Discount Program requirements. Clinics identified with a 10% or greater error rate are receiving focused retraining and ongoing monitoring, with audit results shared with leadership to promote accountability. Two mandatory training sessions for CARs, AR staff, and administrators are being conducted to reinforce consistent and compliant program implementation. Persons Responsible: Steven Hansen, President & CEO; Pearl Lujan, Central Billing Office Director Estimated Completion Date: December 31, 2026
FINDING 2025-002 – SIGNIFICANT DEFICIENCY- REPORTING - INTERNAL CONTROL OVER COMPLIANCE Description of Finding: The Town is required to submit an annual Project and Expenditure report within 30-days of after the close of the reporting period. Statement of Concurrence or Nonconcurrence: The Town agre...
FINDING 2025-002 – SIGNIFICANT DEFICIENCY- REPORTING - INTERNAL CONTROL OVER COMPLIANCE Description of Finding: The Town is required to submit an annual Project and Expenditure report within 30-days of after the close of the reporting period. Statement of Concurrence or Nonconcurrence: The Town agrees with the audit finding. Corrective Action: The Town will establish policies and procedures to ensure the reports are filed on time and accurately. Name of Contact Person: Shelley Cates, Finance Director, (860) 779-3411 x133. Projected Completion Date: June 30, 2026.
Finding Number: 2025-001 Significant Deficiency -Internal Control over Compliance Planned Corrective Action Plan: Health Projects Center will address the finding by talcing the steps outlined below: 1. As of November 2025, Health Projects Center has hired a new Finance Director to strengthen oversig...
Finding Number: 2025-001 Significant Deficiency -Internal Control over Compliance Planned Corrective Action Plan: Health Projects Center will address the finding by talcing the steps outlined below: 1. As of November 2025, Health Projects Center has hired a new Finance Director to strengthen oversight of financial reporting and internal controls. This role will be responsible for ensuring timely and accurate financial close processes and supporting audit readiness. 2. Health Projects Center will implement a more structured and timely year-end close process, with the goal of completing the fiscal year close within the first quarter following year-end. With the improved close timeline, Health Projects Center aims to complete the annual audit by the end of the second quarter. Person Responsible for Corrective Action Plan: John Beleutz, Executive Director Anticipated Date of Completion: June 30, 2026 fiscal year-end
Federal Program: 93.045/93.053, Department of Health and Human Services, Aging Cluster Condition per Auditor:The County engaged a third party contractor to perform certain eligibility reassessments, including obtaining verification of medical necessity, when required. While the County had a process ...
Federal Program: 93.045/93.053, Department of Health and Human Services, Aging Cluster Condition per Auditor:The County engaged a third party contractor to perform certain eligibility reassessments, including obtaining verification of medical necessity, when required. While the County had a process in place to properly identify when reassessment was required and to follow up with the contractor about the status of reassessments, controls did not ensure the third party contractor followed through on reassessments on a timely basis. Planned Corrective Action: The Department of Senior Services would like to clarify that the third party contractor is contracted through The Senior Alliance, the Area Agency on Aging for region 1 C and not Wayne County.Wayne County Senior Services will continue to monitor the third party vendor for timely assessments and reassessments through the existing controls which include:• Providing the third party contractor monthly lists of clients in need of assessment/reassessment• Generating monthly lists of outstanding reassessments (clients not reassessed from the monthly list)• Reminding clients of the requirement for 6 month reassessments• Obtaining updated information (phone numbers, emergency contacts, etc.) twice per year • Providing updated information to third party contractor• Documentation of communicated information regarding third party contractor’s performance to The Senior Alliance Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Joan Siavrakas
Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will...
Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensure that the Director of Affordable Housing submits an allocation sheet each pay period. The COO will check the allocation sheet for accuracy before approving the allocation sheet and submitting to Payroll for processing. The allocation sheet submitted will include detailed information on the job duties performed during that pay period by the staff member submitting the allocation sheet. Additionally, the Director of Affordable Housing will document job duties for each position in the department. Anticipated Completion Date: 7/1/2026 Contact: Jill Lesmerises, CFO
Plan: Please see below the process for obtaining correct documentation including 50059’s. 1. Notification: Tenants are notified in advance to submit required documentation. 2. Tenant Submission: Tenants provide updated income and household info 3. Verification: Property management verifies the submi...
Plan: Please see below the process for obtaining correct documentation including 50059’s. 1. Notification: Tenants are notified in advance to submit required documentation. 2. Tenant Submission: Tenants provide updated income and household info 3. Verification: Property management verifies the submitted information (e.g., contacting employers, reviewing documents). 4. Rent Calculation: Rent is recalculated based on updated income and family composition, per HUD guidelines. 5. 50059 Form: Completing the 50059 form accurately is crucial. It documents eligibility, income, and rent calculations. Errors can lead to incorrect rent, delays, or compliance issues. 6. Finalizing Recertification: After verification and accurate completion of the 50059, tenants are informed of any rent changes. 7. Record-Keeping: All recertification documents, including the 50059 form, are filed for compliance and audit purposes. By ensuring that recertifications are done annually, all tenant information is updated, and 50059 forms are accurately completed, doing so maintains program compliance and ensure that tenants are paying the correct rent based on their current financial situation. This is critical not only for HUD compliance but also for ensuring that tenants receive the appropriate level of assistance. Completion Date: 7/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Finding 2025-003 Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Opera...
Finding 2025-003 Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensure that the Director of Affordable Housing submits an allocation sheet each pay period. The COO will check the allocation sheet for accuracy before approving the allocation sheet and submitting to Payroll for processing. The allocation sheet submitted will include detailed information on the job duties performed during that pay period by the staff member submitting the allocation sheet. Additionally, the Director of Affordable Housing will document job duties for each position in the department. Anticipated Completion Date: 7/1/2026 Contact: Jill Lesmerises, CFO
2025-001 - Lack of Independent Review and Approval of Reporting Auditor Description of Condition and Effect: During our audit procedures over the Township's reporting process, we noted that the annual financial report selected for testing did not include documentation that it was subject to an indep...
2025-001 - Lack of Independent Review and Approval of Reporting Auditor Description of Condition and Effect: During our audit procedures over the Township's reporting process, we noted that the annual financial report selected for testing did not include documentation that it was subject to an independent review and approval prior to submission in order to detect and correct potential errors or omissions. As a result of this condition, the Township was exposed to an increased risk that the report filed could contain errors and not be detected and corrected on a timely basis. Auditor Recommendation: We recommend that the Township establish procedures to ensure that all reports are subject to review and approval by an independent employee prior to submission, and that the review and approval is adequately documented. Corrective Action: We acknowledge the finding of significant deficiency in internal controls over compliance. While the matter is not considered to be material to the overall compliance requirements, we recognize the importance of maintaining robust internal controls to ensure full adherence to applicable regulations and policies. The Township has completed training sessions with relevant personnel on the updated compliance process. The Township has also designated an employee as grants manager to provide additional oversight over grant awards to ensure sustained compliance and timely identification of potential issues. Responsible Person: Corey Schmidt, Finance Director Anticipated Completion Date: December 31, 2026
Management notes that the questioned costs identified in FY2025 represent a continuation of items previously reported in FY2024 and addressed through an established corrective action plan. As part of the prior year response, management implemented a comprehensive action plan and engaged an independe...
Management notes that the questioned costs identified in FY2025 represent a continuation of items previously reported in FY2024 and addressed through an established corrective action plan. As part of the prior year response, management implemented a comprehensive action plan and engaged an independent forensic audit to assess the identified irregularities. Building on these efforts, management is further strengthening internal controls to ensure sustained compliance. These actions include:  Continued implementation and monitoring of corrective measures identified in the prior year audit and forensic review.  Enhanced oversight of credit card issuance, approval, and reconciliation processes.  Reinforced segregation of duties to reduce the risk of unauthorized transactions.  Strengthened monitoring of cash receipts and deposit procedures to ensure all program funds are accurately recorded and deposited promptly.  Ongoing compliance reviews to confirm that prior audit findings are fully resolved and do not recur.
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an up...
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an updated cash disbursement procedure to ensure that Project funds are restricted solely to project-specific operations and are not disbursed on behalf of separate entities. Management is in the process of receiving the full reimbursement of the $255,270 from the affiliated entity. Implementation date: June 30, 2026
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an up...
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an updated cash disbursement procedure to ensure that Project funds are restricted solely to project-specific operations and are not disbursed on behalf of separate entities. Management is in the process of receiving the full reimbursement of the $82,459 from the affiliated entity. Implementation date: June 30, 2026
1. Recommendations: We recommend management implement internal controls surrounding Replacement Reserve deposits to ensure annual HUD increases in the required R&R deposit amounts are promptly identified and communicated to Prudential, so the deposit rate is updated in a timely manner. 2. Action Tak...
1. Recommendations: We recommend management implement internal controls surrounding Replacement Reserve deposits to ensure annual HUD increases in the required R&R deposit amounts are promptly identified and communicated to Prudential, so the deposit rate is updated in a timely manner. 2. Action Taken: Management agrees with the recommendations and will review and implement a procedure to ensure the HUD increases are communicated to Prudential on timely basis. Furthermore, management deposited the delinquent amount of $21,200 into the Replacement Reserve fund in May 2026. Implementation date: June 30, 2026
1. Recommendations: We recommend management implement internal controls surrounding Replacement Reserve deposits to ensure annual HUD increases in the required R&R deposit amounts are promptly identified and communicated to Prudential, so the deposit rate is updated in a timely manner. 2. Action Tak...
1. Recommendations: We recommend management implement internal controls surrounding Replacement Reserve deposits to ensure annual HUD increases in the required R&R deposit amounts are promptly identified and communicated to Prudential, so the deposit rate is updated in a timely manner. 2. Action Taken: Management agrees with the recommendations and will review and implement a procedure to ensure the HUD increases are communicated to Prudential on timely basis. Furthermore, management deposited the delinquent amount of $6,432 into the Replacement Reserve fund subsequent to year-end. Implementation date: June 30, 2026
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an up...
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an updated cash disbursement procedure to ensure that Project funds are restricted solely to project-specific operations and are not disbursed on behalf of separate entities. Management is in the process of receiving the full reimbursement of the $59,971 from the affiliated entity. Implementation date: June 30, 2026
1. Recommendations: We recommend management implement internal controls surrounding Replacement Reserve deposits to ensure annual HUD increases in the required R&R deposit amounts are promptly identified and communicated to Prudential, so the deposit rate is updated in a timely manner. 2. Action Tak...
1. Recommendations: We recommend management implement internal controls surrounding Replacement Reserve deposits to ensure annual HUD increases in the required R&R deposit amounts are promptly identified and communicated to Prudential, so the deposit rate is updated in a timely manner. 2. Action Taken: Management agrees with the recommendations and will review and implement a procedure to ensure the HUD increases are communicated to Prudential on timely basis. Furthermore, management deposited the delinquent amount of $2,380 into the Replacement Reserve fund subsequent to year-end. Implementation date: June 30, 2026
Action taken in response to finding: The Club will implement procedures to periodically review and update internal policies to ensure compliance with current regulatory requirements including requesting auditor review on procurement policies prior to approval. Name(s) of the contact person(s) respon...
Action taken in response to finding: The Club will implement procedures to periodically review and update internal policies to ensure compliance with current regulatory requirements including requesting auditor review on procurement policies prior to approval. Name(s) of the contact person(s) responsible for corrective action: Julie Adelmund Planned completion date for corrective action plan: 05/28/2026
Action taken in response to finding: The Club will utilize expenditures report directly from the accounting system when preparing progress reports to ensure all activity is accurately captured and reported. Name(s) of the contact person(s) responsible for corrective action: Julie Adelmund Planned co...
Action taken in response to finding: The Club will utilize expenditures report directly from the accounting system when preparing progress reports to ensure all activity is accurately captured and reported. Name(s) of the contact person(s) responsible for corrective action: Julie Adelmund Planned completion date for corrective action plan: 05/28/2026
Management acknowledges through our previous responses that this finding is aligned with lack of leadership experience in financial aid. This has been resolved with the hiring of Ruth Casper and the separation of one individual where most of the finding’s evidence associated. Ruth Casper has been gi...
Management acknowledges through our previous responses that this finding is aligned with lack of leadership experience in financial aid. This has been resolved with the hiring of Ruth Casper and the separation of one individual where most of the finding’s evidence associated. Ruth Casper has been given specific direction of expectations and the latitude to enact immediate changes to the Barton College Financial Aid awarding/reporting processes to ensure timely and accurate operations/reporting. All Department of Education and Barton internal deadlines will be adhered to at all times going forward.
Ruth Casper has redesigned Barton’s Return to Title IV worksheet designed to eliminate errors. Additionally, Ruth has been assigned specific responsibility of verification and approval controls before initiating a return to Title IV action can occur without infringing upon required reporting timelin...
Ruth Casper has redesigned Barton’s Return to Title IV worksheet designed to eliminate errors. Additionally, Ruth has been assigned specific responsibility of verification and approval controls before initiating a return to Title IV action can occur without infringing upon required reporting timelines. This situation stemmed primarily from the same person who is no longer at Barton College. Management is assured that this situation will not occur under Ruth Casper’s leadership teamed with the revised internal verification and reporting controls.
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