Corrective Action Plans

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Corrective Action Plan: A revised plan has been developed, and additional standard operating procedures (SOPs) have been implemented to ensure processes are accurate, transparent, and consistently applied. These measures have been established to prevent over-reimbursement and strengthen internal con...
Corrective Action Plan: A revised plan has been developed, and additional standard operating procedures (SOPs) have been implemented to ensure processes are accurate, transparent, and consistently applied. These measures have been established to prevent over-reimbursement and strengthen internal controls over the grant billing process. Management is enhancing segregation of duties, increasing oversight, and monitoring activities, and providing ongoing training to ensure compliance and consistent application of established procedures. Additionally, the guarantor will be notified of the identified discrepancy, and any over-reimbursed funds are in the process of being returned. Individual(s) Responsible: Yolanda Adams Completion Date: Plan has been implemented as of date of audit submission.
Finding 2025-002: Lower Income Housing Assistance Program – Section 8 New Construction/ Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development (Repeat of Finding 2024-003) Compliance Requirements: Special Tests and Provisions Type of finding: In...
Finding 2025-002: Lower Income Housing Assistance Program – Section 8 New Construction/ Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development (Repeat of Finding 2024-003) Compliance Requirements: Special Tests and Provisions Type of finding: Internal Control Over Compliance (material weakness) and Compliance (material noncompliance) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to establish a monitoring process to ensure compliance with Mortgage Restructuring Loan terms and conditions. Action Taken: Action Taken: The Organization has accepted the recommendation to strengthen internal controls regarding Mortgage Restructuring Loan terms. We are currently in active remediation, working in direct coordination with our HUD Account Exexuctive, to ensure our adopted policies align with the federal requirments. Our HUD Account Exexuctive, has been notified of the finalized 2025 Auditied financials and are currently working to set up a time to discuss a Management Action Plan regarding a recommedation for Mortgage Restructuring controls. If these are questions regarding this plan, please call the responsible part at (719)852-5578. Sincerely yours, Brenda Quintana Administrator Tri-County Senior Citizens and Housing, Inc.
March 10, 2026 To: Clausell & Associates, P.C. From: Tabirus Lockhart, Chief Financial Officer of Enrichment Services Programs, Inc. Below is the Agency’s corrective action plan as it relates to the findings for the fiscal year ending July 31, 2024, Single Audit Act audit. Comment #2024-001 INTERNAL...
March 10, 2026 To: Clausell & Associates, P.C. From: Tabirus Lockhart, Chief Financial Officer of Enrichment Services Programs, Inc. Below is the Agency’s corrective action plan as it relates to the findings for the fiscal year ending July 31, 2024, Single Audit Act audit. Comment #2024-001 INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION, GRANT CLOSE-OUT, AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED GENERAL (Repeat) Views of Responsible Officials and Planned Corrective Actions: We concur with this finding - Management is in the process of assessing the organizational structure, capacity to provide adequate financial reporting. With Board review and approval of the Agency’s financial funding sources, the Agency will hire additional fiscal clerk to further support financial requirements and segregation of duties to ensure adequate internal controls are fully implemented. The CFO will have the overall responsibility of properly reconciling and closing out the accounting system and grant activity each month in an efficient and timely manner to eliminate the risk of significant errors occurring. Budget-to-actual schedules will be an integral part of the grant accountant analyst’s basic responsibilities. The fiscal policies and procedures will be updated with the enhancements implemented within the fiscal department. Staff will be trained on revised policies and procedures and Uniform Guidance regulations. The new automated financial systems, will support financial reporting to meet GAAP requirements and to provide informative reports for Board and Management. All enhancements will be implemented by December 31, 2024. Concerning preparation of external reports required by various funding sources (i.e., SF-425, DHS’s reports for LIHEAP, LIHWAP, etc.), the Agency will ensure adequate training is performed to improve the skills and knowledge of key personnel. Policies and procedures will also be revised to support external reporting. Implementation Date: The plan correction date will be completed no later than December 31, 2025. Responsible Person: Tabirus Lockhart, CFO, will be responsible for the corrective action. Comment #2025-002 INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION, GRANT CLOSE-OUT, AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED HEAD START AND EARLY HEAD START, LIHEAP, CSBG, ASTHO, CACFP, and CSLFRF FAL # 93.600, 93.568, 93.569, 93.185, 10.558, 21.027 (Questioned Costs - None) Views of Responsible Officials and Planned Corrective Actions: We concur with the finding. Management and staff are in the process of assessing and updating the policies and procedures over the accounting and reporting of federal and state grants and contracts. In connection with training staff on the new and updated accounting system, we are providing ongoing training on the requirements of the Uniform Guidance and the specific requirements for each individual grant award as outlined in each applicable Compliance Supplement issued by Office of Management and Budget (OMB). We are currently reconciling all cash accounts and completing and amending, where necessary, all SF-425 reports and other external reports required by each funding source (state and federal). We anticipate completing this corrective action by June 30, 2026. See also the response to Comment #2025-001. Implementation Date: The plan correction date will be completed no later than June 30, 2026. Responsible Person: Tabirus Lockhart, CFO, will be responsible for the corrective action.
View of Responsible Officials: The Project agrees with the finding and will replenish the replacement reserve by transferring $15,784 from the operating account to the replacement reserve account for the amount that was withdrawn from the replacement reserve in error. Responsible Party: Collyn Iblin...
View of Responsible Officials: The Project agrees with the finding and will replenish the replacement reserve by transferring $15,784 from the operating account to the replacement reserve account for the amount that was withdrawn from the replacement reserve in error. Responsible Party: Collyn Iblings, CFO Estimated Completion: Resolved. Funds were properly transferred on March 5, 2026.
View of Responsible Officials: Management is aware of the related party receivable and reconciles these balances to be reimbursed timely. The Project will request repayment from the affiliates and will continue to monitor related party activity to ensure the Project does not pay reimbursements or ad...
View of Responsible Officials: Management is aware of the related party receivable and reconciles these balances to be reimbursed timely. The Project will request repayment from the affiliates and will continue to monitor related party activity to ensure the Project does not pay reimbursements or advances to affiliates in excess of allowed expenditures or allowable distributions of surplus cash. Responsible Party: Collyn Iblings, CFO Estimated Completion: Resolved. Related party receivable was properly refunded in April 2026.
View of Responsible Officials: The Project agrees with the finding and will reconcile the replacement reserve account by transferring $14,899 from the replacement reserve to the operating account to properly reconcile the replacement reserve for the allowable costs and withdrawals approved by HUD. R...
View of Responsible Officials: The Project agrees with the finding and will reconcile the replacement reserve account by transferring $14,899 from the replacement reserve to the operating account to properly reconcile the replacement reserve for the allowable costs and withdrawals approved by HUD. Responsible Party: Collyn Iblings, CFO Estimated Completion: Resolved. Funds were properly transferred on March 5, 2026.
Finding 2025-003: ALN 20.106 ABIA FAA, 3-48-0359-067-2021, 3-48-0359-071-2022, 3-48-0359-074-2024, 3-48-0359-073-2024, 3-48-0359-075-2024, 3-48-0359-077-2025, 3-48-0359-078-2025, 3-48-0359-079-2025, U.S. Department of Transportation — Significant Deficiency in Internal Control over Reporting and Fin...
Finding 2025-003: ALN 20.106 ABIA FAA, 3-48-0359-067-2021, 3-48-0359-071-2022, 3-48-0359-074-2024, 3-48-0359-073-2024, 3-48-0359-075-2024, 3-48-0359-077-2025, 3-48-0359-078-2025, 3-48-0359-079-2025, U.S. Department of Transportation — Significant Deficiency in Internal Control over Reporting and Finding of Non-compliance Contact Person – Lyn Estabrook, Deputy Chief, Airport Development Management Response – Concur. The Aviation Department has completed a thorough internal review of its FAA Airport Improvement Program (AIP) and other FAA grant reporting practices in response to the audit’s draft finding. This evaluation saw gaps in documentation and deadline management that contributed to delays and inconsistencies in required FAA performance reporting. While project updates were regularly communicated during monthly ADO coordination meetings and with Airport program wide written monthly reports these updates did not meet the FAA’s formal submission requirement for their written performance reports within 30 days of the close of each reporting period. To address these issues comprehensively and sustainably, the Department has already implemented significant process improvements, including the assignment of a dedicated Project Coordinator, formalization of reporting workflows, and establishment of a centralized reporting repository. The Division has also issued a fully documented FAA Grant Reporting Procedure and implemented annual mandatory training to ensure staff knowledge, consistency, and long-term compliance. These corrective actions are designed to prevent recurrence, enhance accountability, and ensure all future performance reports are completed, submitted, and documented in accordance with FAA requirements. See below write up of the Corrective Action Taken and Planned: 1. Project Coordinator Assigned: A dedicated Project Coordinator (PC) now manages report tracking, deadlines, and documentation control. 2. Annual Mandatory Training: • Training held February 5, 2026 • Annually recurring every October (new fiscal year) • Covers: o FAA forms o Deadlines o Submission requirements o Documentation standards 3. Formal 30 Day Reporting Controls: • Tracker auto calculates deadlines • PMs receive calendar invites and reminders at 21, 14, 7, and 3 days • FAA submissions now require CC to: o Project Coordinator o Airport Deputy Chief (Lyn Estabrook) o CIP Finance Manager (Cathy Brown) • Evidence of sent email placed in centralized repository 4. Centralized Evidence Repository: • All submitted forms, sent emails, and FAA acknowledgments stored in one location • Reduces risk of buried project files • Supports complete, auditable documentation 5. Procedure Issued: The FAA Grant Reporting Procedure has been issued and is now mandatory Division policy. 6. Timeline & Monitoring: • Immediate: Controls implemented in March 2026 • Next 90 Days: Review effectiveness after full quarterly cycle • Ongoing: o Annual training at beginning of the fiscal year o Quarterly internal reviews o Annual procedure update aligned to any FAA changes Estimated Completion – June 30, 2026.
National Student Loan Data System (NSLDS) Enrollment Reporting Recommendation: We recommend the University review its reporting procedures to ensure the students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is...
National Student Loan Data System (NSLDS) Enrollment Reporting Recommendation: We recommend the University review its reporting procedures to ensure the students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The reporting data wasn’t being sent timely to NSLDS, as a result of process and procedural changes at the University. With new personnel in positions and changing processes, management is confident in data feeding NSLDS within the 60 day period after thorough review of the process overall. This includes a remediation effort of IT data feeds to the NSLDS and the compilation of data. As the enrollment data is not sent on a daily/frequent basis, the next reporting cycle (coming month), the process will be investigated and triaged as necessary. Names of the contact persons responsible for corrective action: Josh Perkins, AVP – Finance/Admin; Kevin Klawonn, Director - IT Planned completion date for corrective action plan: 6/1/2026
Common Origination & Disbursement (COD) Reporting Recommendation: We recommend the University establish a process to ensure that all disbursement information is accurately reported to the COD system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Act...
Common Origination & Disbursement (COD) Reporting Recommendation: We recommend the University establish a process to ensure that all disbursement information is accurately reported to the COD system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The finding was ultimately caused by a syncing error of a batch job process that sends disbursement data to COD from our legacy (now retired) system that has since been replaced, as of October 2025. This was viewed as a one-off occurrence, not a broader systematic issue. The new system is better configured to accurately report disbursement information accurately. Further, Management has undergone a review of findings, and confirmed batch information is configured to send COD information accurately as of the finding notification date. Names of the contact persons responsible for corrective action: Josh Perkins, AVP – Finance/Admin; Kevin Klawonn, Director - IT Planned completion date for corrective action plan: April 30, 2026
Management concurs with the finding and the auditor's recommendation to utilize an interest-bearing account for project funds. Management is in the process of evluating the recommendation to determine an appropriate course of action.
Management concurs with the finding and the auditor's recommendation to utilize an interest-bearing account for project funds. Management is in the process of evluating the recommendation to determine an appropriate course of action.
Management is evaluating policy changes. This is a material weakness related to Section II Financial statements.
Management is evaluating policy changes. This is a material weakness related to Section II Financial statements.
In order to avoid recurrence of such errors in future years, LSNC is implementing a checklist for integrity reports (a draft of which is attached to this memo) and a mid-year programwide integrity report process to identify and correct errors. The checklist of integrity reports will be used and reta...
In order to avoid recurrence of such errors in future years, LSNC is implementing a checklist for integrity reports (a draft of which is attached to this memo) and a mid-year programwide integrity report process to identify and correct errors. The checklist of integrity reports will be used and retained by the executive assistant and the interim executive director to verify that all necessary reports are run and reviewed twice each year. A copy of each report will be retained with the checklist as an additional verification measure. The mid-year review will occur in June or July and will include income and asset eligibility checks on closed cases - using a report of all closed cases that shows the household composition, asset amount and the LSC eligibility selection for each case. The interim executive director and the executive assistant responsible for programwide integrity reports will both review the report and examine any cases that exceed the asset limit for the case household size. Ineligible cases will be corrected to indicate they are not LSC-eligible, meaning that they will not be reported. If LSC funds were used to support the case, those time entries will be changed to charge appropriate funds and staff will prepare revised timesheets. The same review will be repeated at the end of the calendar year, before case data is reported to LSC (and prior to the self-inspection process). This additional review should further strengthen the processes already in place. This process is not time limited. It will be added to LSNC's regular compliance activities. If you have any questions or concerns about LSNC's proposed plan, please contact me at (916) 551-2179 or via email at jaguilar@lsnc.net.
Signing of invoices have been added to our procedures when submitting invoices for payment. The required staff were notified of this addition to the procedures.
Signing of invoices have been added to our procedures when submitting invoices for payment. The required staff were notified of this addition to the procedures.
We will strengthen on our controls to ensure timely communication with private shcools regarding equitable services.
We will strengthen on our controls to ensure timely communication with private shcools regarding equitable services.
CWA management is in agreement with this finding. They will develop and implement procedures ensure the timely submittal of required reports.
CWA management is in agreement with this finding. They will develop and implement procedures ensure the timely submittal of required reports.
Management of CWA agrees with this finding and intends to develop and implement written internal control policies and procedures by December 31, 2026. Applicable employees will be trained in these policies and procedures by December 31, 2026.
Management of CWA agrees with this finding and intends to develop and implement written internal control policies and procedures by December 31, 2026. Applicable employees will be trained in these policies and procedures by December 31, 2026.
CWA management is in agreement with this finding. They will develop and implement procedures requiring monthly independent reconciliations of all accounts to include bank reconciliations as well as the review of both journal entries and disbursements by an appropriate supervisor.
CWA management is in agreement with this finding. They will develop and implement procedures requiring monthly independent reconciliations of all accounts to include bank reconciliations as well as the review of both journal entries and disbursements by an appropriate supervisor.
Recommendation: We recommend that management notify LSC prior to entering into any lease with an accessibility certification. Explanation of disagreement with audit finding: There is no disagreement with this finding Action taken in response to finding: Legal Aid Chicago’s new office space is fully ...
Recommendation: We recommend that management notify LSC prior to entering into any lease with an accessibility certification. Explanation of disagreement with audit finding: There is no disagreement with this finding Action taken in response to finding: Legal Aid Chicago’s new office space is fully ADA accessible. The current lease runs through February 28, 2041. Should Legal Aid Chicago choose to not extend the existing lease and relocate to a new location upon its expiration, we will be sure to provide formal notification and confirmation of ADA accessibility prior to lease execution. Name of the contact person responsible for corrective action: Teresa Sullivan, Deputy Director / General Counsel Planned completion date for corrective action plan: December 31, 2040
Recommendation: We recommend that management implement a control to ensure complete documentation is maintained for all cases that require retainer agreement. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: Legal Aid Ch...
Recommendation: We recommend that management implement a control to ensure complete documentation is maintained for all cases that require retainer agreement. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: Legal Aid Chicago's Deputy Director/General Counsel has already contacted the employees who made the errors with respect to missing retainers and has included their supervisors in the communication to ensure compliance on a forward-looking basis. The Deputy Director/General Counsel will also hold a compliance training for staff covering LSC regulations by the end of Q3 2026. Name of the contact person responsible for corrective action: Teresa Sullivan, Deputy Director / General Counsel Planned completion date for corrective action plan: September 30, 2026
Recommendation: We recommend that management implement a control to review PAI time entries to ensure they are accurate. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: While issues with PAI time for non-case activity w...
Recommendation: We recommend that management implement a control to review PAI time entries to ensure they are accurate. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: While issues with PAI time for non-case activity were successfully remediated with the implementation of a required drop-down activity description field in the LegalServer case management system, the two erroneous entries in 2025 involved case time and resulted from cases that were opened as PAI “Yes” due to the intake occurring at a volunteer clinic and the expectation of volunteer attorney involvement that did not ultimately occur. Legal Aid Chicago's Deputy Director/General Counsel has already contacted the employees who made the errors with respect to PAI time and has included their supervisors in the communication to ensure compliance on a forward-looking basis. The Deputy Director/General Counsel will also hold a compliance training for staff covering LSC regulations by the end of Q3 2026. Name of the contact person responsible for corrective action: Teresa Sullivan, Deputy Director / General Counsel Planned completion date for corrective action plan: September 30, 2026
Corrective Action: Procedures will be implemented to reflect the modified cash basis of accounting, which is the method used for the budget, so that the City Clerk makes the necessary adjusting journal entries. Proposed completion date: The Board will implement the above procedure immediately.
Corrective Action: Procedures will be implemented to reflect the modified cash basis of accounting, which is the method used for the budget, so that the City Clerk makes the necessary adjusting journal entries. Proposed completion date: The Board will implement the above procedure immediately.
Finding Number: 2025-001 Condition: The Township submitted the required reports, but one of the reports submitted did not properly identify the federal expenditures paid during the reporting period. Planned Corrective Action: The Township will implement a reconciliation and review process requiring ...
Finding Number: 2025-001 Condition: The Township submitted the required reports, but one of the reports submitted did not properly identify the federal expenditures paid during the reporting period. Planned Corrective Action: The Township will implement a reconciliation and review process requiring all reported federal expenditures to be verified against the general ledger and supporting documentation prior to submission. In addition, the Township will correct the identified errors and resubmit the report with accurate federal expenditure information. Contact person responsible for corrective action: Wendy Hillman Anticipated Completion Date: 12/31/2026
Recommendation: We recommend that management re-evaluate its policies and procedures to ensure an appropriate member of management is in place to review all expenditures charged to federal awards, as well obtaining the approval of the federal agency when changes are made that would impact funding an...
Recommendation: We recommend that management re-evaluate its policies and procedures to ensure an appropriate member of management is in place to review all expenditures charged to federal awards, as well obtaining the approval of the federal agency when changes are made that would impact funding and or amounts charged to the federal program. Action Taken: Management has implemented revised policies and procedures in place to strengthen the controls over activities allowed and unallowed and allowable costs to reduce the risk of inaccurate, unallowable, or wrongly allocated expenses charged to the federal program.
CORRECTIVE ACTION PLAN Name of Auditee: Cedar Street Senior Apartments, Inc. HUD Project No. 121-EE118-NP-WAH Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: July 1, 2024 through June 30, 2025 CAP Prepared By: Name: Chrissie Keeney Position: Corporate Controller Phone...
CORRECTIVE ACTION PLAN Name of Auditee: Cedar Street Senior Apartments, Inc. HUD Project No. 121-EE118-NP-WAH Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: July 1, 2024 through June 30, 2025 CAP Prepared By: Name: Chrissie Keeney Position: Corporate Controller Phone: (707) 822-9000 Finding 2025-001 Comments: Management Agrees with the finding. Actions: Management will implement controls and monitor the reserve for replacement account to ensure the reserve for replacement cash account is fully funded each year in accordance with the Regulatory Agreement.
CORRECTIVE ACTION PLAN Name of Auditee: 703 Cedar Street, Inc. HUD Project No. 121-EE-147-NP-WAH Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: July 1, 2024 through June 30, 2025 CAP Prepared By: Name: Chrissie Keeney Position: Corporate Controller Phone: (707) 822-9...
CORRECTIVE ACTION PLAN Name of Auditee: 703 Cedar Street, Inc. HUD Project No. 121-EE-147-NP-WAH Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: July 1, 2024 through June 30, 2025 CAP Prepared By: Name: Chrissie Keeney Position: Corporate Controller Phone: (707) 822-9000 Finding 2025-001 Comments: Management Agrees with the finding. Actions: Management will implement controls and monitor the reserve for replacement account to ensure the reserve for replacement cash account is fully funded each year in accordance with the Regulatory Agreement.
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