Corrective Action Plans

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2025-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2026
2025-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2026
The Department of Behavioral Health (DBH) agrees with the findings and will put controls in place to resolve the issue. On May 20, 2026, DBH trained all grants staff on how to use combo codes in the timekeeping system (Peoplesoft) so that individuals whose time is split across grants or split betwee...
The Department of Behavioral Health (DBH) agrees with the findings and will put controls in place to resolve the issue. On May 20, 2026, DBH trained all grants staff on how to use combo codes in the timekeeping system (Peoplesoft) so that individuals whose time is split across grants or split between grant and local projects can record their time to each funding source. This new process will be rolled out starting June 12, 2026.
The Economic Security Administration (ESA) concurs with this finding. ESA will review its current case review procedures to ensure that prioritization of assignments aligns with regulatory timeliness requirements. Based on the results of this review, ESA will update its procedures as needed.
The Economic Security Administration (ESA) concurs with this finding. ESA will review its current case review procedures to ensure that prioritization of assignments aligns with regulatory timeliness requirements. Based on the results of this review, ESA will update its procedures as needed.
The Child and Family Services Agency (CFSA) concurs with the finding. CFSA has instituted a point-of-payment invoice validation and cost determination process that will allow the Agency to retire the quarterly expenditure reporting process in its entirety. Providers submit invoices that align with t...
The Child and Family Services Agency (CFSA) concurs with the finding. CFSA has instituted a point-of-payment invoice validation and cost determination process that will allow the Agency to retire the quarterly expenditure reporting process in its entirety. Providers submit invoices that align with their contract schedules and they self-report on a schedule-oriented tool. The CFSA team reviews, validates, and approves each and every invoice. The tool tracks invoiced cost for the entire fiscal year such that by year’s end there is a verified, validated catalogue of reported costs that are used to derive the family-based rate that drive the adjustment claims for these special tests and provisions.
The Child and Family Services Agency (CFSA) concurs with the finding. The June 2025 implementation of STAAND, CFSA’s new system, included safeguards to mitigate the generation of claims for federal reimbursement for payments made to any provider for which there is a critical licensure issue.
The Child and Family Services Agency (CFSA) concurs with the finding. The June 2025 implementation of STAAND, CFSA’s new system, included safeguards to mitigate the generation of claims for federal reimbursement for payments made to any provider for which there is a critical licensure issue.
The Department of Human Services (DHS) agrees with the findings and will work within the Division of Customer Workforce Employment and Training (DCWET) team to mitigate the causes of the findings. These findings are mostly caused by inconsistency of caseload management practices. Another mitigating ...
The Department of Human Services (DHS) agrees with the findings and will work within the Division of Customer Workforce Employment and Training (DCWET) team to mitigate the causes of the findings. These findings are mostly caused by inconsistency of caseload management practices. Another mitigating factor is attributable to glitches in information technology around the sanction process. DCWET has been working with OIS to eliminate inaccuracies in customer assignments. DCWET conducted a systematic review of each caseload to ensure that customers are properly assigned to PITs, which allows effective tracking of their participation (non-participation) leading to sanctioning and reduction in benefits. The PIT Clean-Up exercise was implemented on May 6, 2026. The PIT Clean up exercise has significantly enhanced the operational efficiency of each assigned PIT. Customers who were not participating in the TEP program were identified and placed in special PIT from which they will go through the sanctioning process and ultimately see their benefits reduced. The second issue is glitches in information technology, which have caused inconsistencies in the non-compliance period for non-participating customers. DCWET is working with the OIS to automate the sanction process to ensure that the required non-compliance outreach efforts are timely completed and customers sanctioned. The automation process would eliminate inconsistencies in executing the required outreach efforts. The automation process development started on May 20, 2026, and will be implemented on October 1, 2026.
The Department of Human Services (DHS)/Economic Security Administration (ESA) agree with the auditor’s findings regarding the lack of completion of requests from the Child Support Enforcement (CSE) to the TANF program to impose a child support on parents who have not cooperated with Child Support co...
The Department of Human Services (DHS)/Economic Security Administration (ESA) agree with the auditor’s findings regarding the lack of completion of requests from the Child Support Enforcement (CSE) to the TANF program to impose a child support on parents who have not cooperated with Child Support compliance requirements. The incomplete work was due to staff transitions occurring during the review period which impacted the oversight and productivity of DHS – ESA staff working on the child support sanction process. The following corrective action plan has been developed by DHS/ESA to address the findings. These controls would provide DHS/ESA with the ability to identify discrepancies, promote accountability, and ensure that actions are carried out timely and accurately. The work will be performed by staff working in the Division of Customer, Workforce Employment and Training (DCWET). The DCWET leadership will: • Conduct training sessions for the newly assigned staff to ensure they understand the procedures and expectations to complete the required tasks. The training will also provide clarity about the procedures for imposing a child support sanction and lifting a child support sanction. The lack of clarity was caused by the sanction team’s staff turnover and inability to timely backfill vacancies due to budget constraints. A new staff has been assigned to the team, and OPM has updated the manual that contains the procedures for imposing and lifting child support sanctions. • Implement an internal digital tracking system to ensure completion of all required tasks in a timely and accurate manner. This will include a process to re-assign work when staff are on leave for two or more days. OPM is working with OIS to automate some of the manual processes while retaining the integrity of the process. OPM will collaborate with OIS to automate both the non -cooperation sanction imposition and lifting. OIS will create a digital tracking system that would lead to improvement in the supervision, tracking, and monitoring of staff daily activities and completion of assignments. • Increase supervision and monitoring of employees responsible for completing the requests from the Office of the Attorney General OAG by conducting scheduled follow-up reviews to monitor progress of work and provide guidance to staff, as needed. • Review the procedures document to ensure that the process of calculating sanctions and benefit amounts as well as the content of sanction letters are accurate and timely.
The Department of Human Services (DHS) agrees with the findings, and we’ll work with the DCAS and DICM teams to mitigate the causes of the findings. These findings are mostly residual issues with the tables in DHS/ESA DCAS system. ESA needs to enhance DCAS to tie the income evidence in the income su...
The Department of Human Services (DHS) agrees with the findings, and we’ll work with the DCAS and DICM teams to mitigate the causes of the findings. These findings are mostly residual issues with the tables in DHS/ESA DCAS system. ESA needs to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. This would be automating the process by connecting the 2-step process into one task. This automation process would be a permanent solution to curbing stale and unsubstantiated hours from migrating to Q5i. DCWET will work with DICM to request that a JIRA ticket be created to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. The ESA DPO needs to conduct staff training (re-training) of all SSR on the DCAS screens which require action to confirm employment. This means that the DPO should dedicate resources to providing adequate training to SSRs involved in updating customers’ employment information in DCAS. The DCWET Deputy Administrator will take the lead with the DPO counterpart to implement the necessary training starting before September 30, 2027.
The Division of Program Operations (DPO) of DHS acknowledges and agrees with the audit findings and related observations. After reviewing the issues identified, DPO is implementing targeted corrective measures to strengthen internal controls and ensure full compliance with eligibility documentation ...
The Division of Program Operations (DPO) of DHS acknowledges and agrees with the audit findings and related observations. After reviewing the issues identified, DPO is implementing targeted corrective measures to strengthen internal controls and ensure full compliance with eligibility documentation requirements. DPO remains committed to executing these corrective actions promptly and maintaining strong internal controls that support accurate eligibility determinations, program integrity, and adherence to federal and District requirements. DPO, in collaboration with DCAS and the Policy Unit, has initiated efforts to align the required language with the DCAS electronic platform and the caseworker portal’s IEG scripts.
The Department of Health (DC Health) concurs with the finding. DC Health and OCFO will coordinate the development and implementation of a standard operating procedure to ensure that program administrators are implementing a secondary review of journal requests and OCFO accountants maintain a trackin...
The Department of Health (DC Health) concurs with the finding. DC Health and OCFO will coordinate the development and implementation of a standard operating procedure to ensure that program administrators are implementing a secondary review of journal requests and OCFO accountants maintain a tracking record of all journal requests and properly review each request to ensure the expenditure is not duplicated via a journal entry.
The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. Management action plan includes the following steps: • The Office of the Registrar will continue to use National Student Clearinghouse third party reporting tool to report enrollment data...
The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. Management action plan includes the following steps: • The Office of the Registrar will continue to use National Student Clearinghouse third party reporting tool to report enrollment data to NSLDS. • The Office of the Registrar continues to utilize the "Submission schedule tool" to keep us compliant with the timeframe required for submission of the reports. • Students who have been reported during the first week of courses as "Never Attended - NA" will be dropped from their courses for the term no more than 1 week after the end of attendance verification. • The Enrollment Time Status (Full Time, Part Time, etc.) for student who are enrolled in Summer courses will be updated effective immediately.
The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. Management action plan includes the following steps: The Office of Financial Aid is implementing enhanced controls to strengthen the accuracy and timeliness of its Return of Title IV Fund...
The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. Management action plan includes the following steps: The Office of Financial Aid is implementing enhanced controls to strengthen the accuracy and timeliness of its Return of Title IV Funds (R2T4) processes. Moving forward, all official and unofficial R2T4 calculations will be subject to more comprehensive review, replacing the prior practice of reviewing a limited sample. To further support compliance and coordination, automated email notifications will be issued to designated staff responsible for both loan and Pell Grant reporting whenever an R2T4 is processed. This will ensure timely awareness and appropriate action by all relevant parties. In addition, staff calendars will be updated to include critical regulatory deadlines associated with the return of Title IV funds. These calendar controls are intended to reinforce adherence to federal requirements and promote consistency across all cases. These measures are designed to improve oversight, enhance internal controls, and ensure full compliance with federal Title IV regulations. The Office of Financial Aid acknowledges that elements of these controls had been previously identified and implemented; however, these processes will be further strengthened, formalized, and consistently applied to ensure full compliance with federal Title IV regulations.
The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. Management action plan includes the following steps: • The Bursar or designee shall run a report daily of all Title IV disbursements that occurred on the prior business day. • The Bursar ...
The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. Management action plan includes the following steps: • The Bursar or designee shall run a report daily of all Title IV disbursements that occurred on the prior business day. • The Bursar or designee will run a report for Title IV funding awarded the previous day for the terms shown on the disbursement report above and select students who had a Title IV disbursement based upon the report above. • The students with the disbursements shall be reviewed in addition to any other student shown having a Title IV Credit balance to determine if a non-refunded Title IV credit balance exist. • Where a non-refunded Title IV credit balance exist, the student shall be included in the list of refunds named Refund Review Report dd/mm/yyyy to be processed following the institution refund process for Title IV Credit Balances. • At the end of the day, the Bursar or designee shall generate a report showing the refunds entered in the system for that day and confirm all previously identified Title IV refunds credit balance refunds were completed and attach said report to the refund review report and save in a designated folder. • The Bursar or designee will complete the batch release process daily to allow refund entered on student records to be transmitted to AP following institutional process. • On the AP check run date, the Bursar or designee shall review the check run notification from AP to confirm all refunds entered in the system since last check run date have been processed successfully. • We will conduct collective training with staff involved in student credit processing as it pertains to Department of Education regulations. Additionally, we will train Staff to ensure understanding of the Corrective Action Plan (CAP) to be taken.
The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. Management action plan includes the following steps: The Office of Financial Aid has recognized irregularities in the student disbursement notification process. The office currently utili...
The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. Management action plan includes the following steps: The Office of Financial Aid has recognized irregularities in the student disbursement notification process. The office currently utilizes Banner Communication Management (BCM) as the primary system for delivering required notifications to students. While this system has historically functioned effectively, recent observations indicated inconsistencies that impacted the timely delivery of certain required notices. In response, the office will initiate enhancements to its notification procedures. Specifically, we will implement a supplementary notification process that will include the use of our new platform, Salesforce. The use of Salesforce should help to provide a reliable communication system for our messages. This dual process approach is intended to strengthen reliability and provide redundancy in the delivery of required communications. These improvements are designed to ensure that all disbursement notifications are transmitted within required timeframes, in full compliance with federal Title IV regulations.
The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. The Office of Financial Aid experienced staff turnover, which impacted the timeliness of reporting submissions to the Common Origination and Disbursement (COD) system. This challenge was ...
The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. The Office of Financial Aid experienced staff turnover, which impacted the timeliness of reporting submissions to the Common Origination and Disbursement (COD) system. This challenge was further compounded by the need to train and cross-train staff to ensure continuity in reporting responsibilities. To address this issue, the office has identified and trained two staff members who are capable of originating and submitting enrollment reporting to COD. Additionally, we have implemented enhanced internal controls, including weekly reporting processes, to ensure compliance with all required deadlines. These measures are designed to ensure that records are submitted within the mandated 15-day timeframe.
The Office of the Deputy Mayor for Planning and Economic Development (DMPED) does not concur with the auditor’s finding regarding the allowability of subtenant improvement allowance per the CPF guidance. DMPED has sought express approval from the Federal awarding agency (U.S. Department of Treasury)...
The Office of the Deputy Mayor for Planning and Economic Development (DMPED) does not concur with the auditor’s finding regarding the allowability of subtenant improvement allowance per the CPF guidance. DMPED has sought express approval from the Federal awarding agency (U.S. Department of Treasury) regarding the use of funds. DMPED has evaluated its procedures to ensure only allowable expenses are charged to the program as required under 2 CFR Section 200.403. DMPED determined in FY25 that it needed to seek approval from the awarding Federal agency on allowable costs, which it completed in 2026.
The Office of the Chief Financial Officer/Office of Finance and Treasury (OCFO/OFT) for Department of Human Services (DHS) concurs with this finding. Quarterly UPO internal audits and Quarterly Regis audits will continue to assist in identifying areas of noncompliance and improvement. In addition, t...
The Office of the Chief Financial Officer/Office of Finance and Treasury (OCFO/OFT) for Department of Human Services (DHS) concurs with this finding. Quarterly UPO internal audits and Quarterly Regis audits will continue to assist in identifying areas of noncompliance and improvement. In addition, the EBT Manager and Supervisors will implement enhanced review and validation procedures of daily card production documentation, including targeted quality checks and supervisory oversight, to ensure alignment with established requirements. Employees will be held accountable for performing in accordance with documented procedures, and corrective actions will be applied as needed to address gaps. These efforts are intended to improve consistency, reduce risk, and ensure sustained compliance with program requirements.
The Department of Human Services (DHS) and Department of Health Care Finance (DHCF) DC Access System (DCAS) team agree with the findings. For the twelve (12) findings, DHS/ESA has identified the description of the deficiencies, examined the magnitude and geographic extent of the deficiencies, identi...
The Department of Human Services (DHS) and Department of Health Care Finance (DHCF) DC Access System (DCAS) team agree with the findings. For the twelve (12) findings, DHS/ESA has identified the description of the deficiencies, examined the magnitude and geographic extent of the deficiencies, identified the actions completed to eliminate the deficiencies. The District will focus on efforts that will create the maximum impact, which includes creating new options for collaboration, streamlining current communication, and introducing cross-functional prioritization. These strategies will help the District move projects toward completion and are rooted in continuous quality improvement. To guide its strategic efforts and track its impact, DHS has outlined the following four phases of corrective action plans to be taken to ensure the deficiencies will be eliminated: • Review and Prioritization, • Design and Development, • Implementation, and • Monitor and Evaluation. Each phase has several process steps including a completion document that signals the permission to move to the next phase. The detailed process steps are documented under DHS’ Consolidated Semi-Annual SNAP Advance Warning Letter Corrective Action Plan and FFY2026 Quality Control Corrective Action Plan reports. The corrective action plan is facilitated by the Quality Improvement Program and since implementing this process in January 2021, the District has identified root causes for errors and gaps in internal auditing and evaluation processes. Therefore, the flow of the semi-annual corrective action plans reflects the District’s commitment to a collaborative corrective action plan - expanding the data analysis section to include data and analysis of internal methods, a complete summary of each phase completed, and a timeline for upcoming phase/project completion.
FINDING – Federal Award Finding 2025-001: Agency: U.S. Department of Health and Human Services (CSBG) Program: Community Service Block Grant (AL No. 93.569) Significant Deficiency and Noncompliance over Allowable Costs / Period of Performance Repeat Finding: No Condition: During our testing over all...
FINDING – Federal Award Finding 2025-001: Agency: U.S. Department of Health and Human Services (CSBG) Program: Community Service Block Grant (AL No. 93.569) Significant Deficiency and Noncompliance over Allowable Costs / Period of Performance Repeat Finding: No Condition: During our testing over allowable costs, we identified 2 transactions in the amount of $38,225 that were incurred in fiscal years 2022 and 2023; however, those costs were recorded as federal expenditure and revenue in fiscal year 2025. The current CSBG grant covering fiscal year 2025 covers the period October 1, 2024 – September 30, 2025, as such, those costs were recorded outside of the period of performance and as such are unallowable. Recommendation: We recommend that management strengthen controls over the timing of federal expenditure recognition to ensure costs are recorded in the proper period of performance. Additionally, the entity should implement procedures to review and reconcile expected expenses to actual invoices received on a periodic basis to ensure all vendor invoices have been timely received. Auditee Response and Corrective Action Plan: UPO has recently implemented two methods for procuring goods and services to address the noted condition. Use of the P-Card for micropurchases and the Purchase Request for larger purchases. P-Card purchases will allow recurring vendor invoices and payments to be captured in real time and recorded in the appropriate billing and funding period. Mandatory use of Purchase Request/PO for all other purchases, to allow the program and finance team to monitor invoices and obligations, and record them within the funding period.
Management’s Action Plan: Management concurs with the findings. The deficiency was due to a lapse in management oversight related to the review and approval of independent contractor timesheets. To strengthen internal controls and ensure compliance with federal requirements, management has implement...
Management’s Action Plan: Management concurs with the findings. The deficiency was due to a lapse in management oversight related to the review and approval of independent contractor timesheets. To strengthen internal controls and ensure compliance with federal requirements, management has implemented corrective actions through the full implementation of a new enterprise resource planning system, Fusion. Under this process, all timecards are now entered, reviewed, and approved directly within Fusion and cannot be processed for payment unless they have been formally approved by appropriate management personnel. This ensures proper documentation, accountability, and adherence to internal control policies. Name of Person Responsible for the Plan: Katherine Hill, Manager of Accounting Jason Lynn, Vice President of Finance and Controller Anticipated Completion Date of the Plan: Completed – fully implemented with the rollout of the Fusion system (May 2025).
All programs Recommendation: We recommend the District implement procedures to monitor audit reporting deadlines and ensure the data collection form and reporting package are submitted to the Federal Audit Clearinghouse within the required timeframe. Explanation of disagreement with audit finding: T...
All programs Recommendation: We recommend the District implement procedures to monitor audit reporting deadlines and ensure the data collection form and reporting package are submitted to the Federal Audit Clearinghouse within the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We had a different auditing firm and were under the impression they had submitted it. We will ensure we will not be late again and submit it on time. . Name(s) of the contact person(s) responsible for corrective action: Stacy Rodriguez Director of Finance Planned completion date for corrective action plan: September 2025
Child Nutrition Cluster – Assistance Listing No. 10.CNC Recommendation: We recommend the District implement a formal process requiring documented evidence of review and approval of all reimbursement requests prior to submission, such as dated sign-offs or electronic approval records, to strengthen i...
Child Nutrition Cluster – Assistance Listing No. 10.CNC Recommendation: We recommend the District implement a formal process requiring documented evidence of review and approval of all reimbursement requests prior to submission, such as dated sign-offs or electronic approval records, to strengthen internal controls and ensure compliance with Federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will provide formal documentation by reviewing and signing the claims for approval of reimbursement requests before submission to the state. Name(s) of the contact person(s) responsible for corrective action: Stacy Rodriguez Director of Finance Planned completion date for corrective action plan: September 2025
Audit Finding Reference Number: 2025 – 002 Finding: NERACOOS recorded federal grant revenue for certain grants related to FY2025 activities in FY2026, based on the timing of reimbursement receipts rather than when the underlying expenditures were incurred. As a result, federal grant revenue and rela...
Audit Finding Reference Number: 2025 – 002 Finding: NERACOOS recorded federal grant revenue for certain grants related to FY2025 activities in FY2026, based on the timing of reimbursement receipts rather than when the underlying expenditures were incurred. As a result, federal grant revenue and related receivables for FY2025 were understated, while revenue in FY2026 was overstated for the related amounts. In addition, this may lead to misstatements in financial reporting if similar cutoff issues occur in future periods. Corrective Action Plan: Develop and implement a formal year-end revenue cutoff checklist specifically for federal grants. The checklist will require a review of all active federal awards within 60 days and then again in 30 days of fiscal year-end to identify allowable expenditures incurred but not yet reimbursed. Establish a procedure to record grant receivables and revenue accruals for identified unbilled costs prior to closing the accounting records each fiscal year. Train the Finance staff responsible for grant accounting on the accrual basis requirements under 2 CFR Part 200 and proper cutoff procedures. Incorporate a supervisory review step into the year-end close process to verify that all grant-related receivables and revenue accruals have been posted before the books are closed. Incorporate the cutoff review into the annual audit preparation timeline and document results for auditor review. Review the FY2025 federal financial reports submitted for CFDA 11.012 to determine whether any amendments or corrections are required, and coordinate with the federal agency as appropriate. Prior to submission of any federal financial reports (e.g., SF-425 Federal Financial Reports), confirm that recorded grant revenue and expenditures reflect all accrued amounts throughout the reporting period. Review draft federal financial reports against the general ledger before submission to verify consistency between reported and recorded amounts. Responsible Official: Jake Kritzer, Executive Director Anticipated Completion Date: September 30, 2026
FINDING 2025-004 The City does not have documented procurement policies and procedures in place as required by the Uniform Guidance. Furthermore, the City did not monitor contractor compliance with BABA provisions. Management’s Response The City will adopt documented procurement policies and procedu...
FINDING 2025-004 The City does not have documented procurement policies and procedures in place as required by the Uniform Guidance. Furthermore, the City did not monitor contractor compliance with BABA provisions. Management’s Response The City will adopt documented procurement policies and procedures and monitor contractor compliance with BABA provisions in FY 2026.
Poverty and Social Reform Institute Dba Leaps and Bounds Family Services has updated the policies and procedures for the agency to reflect the Uniform Guidance requirements regarding the process and controls used to administer federal awards. These changes address the issue of non-compliance by form...
Poverty and Social Reform Institute Dba Leaps and Bounds Family Services has updated the policies and procedures for the agency to reflect the Uniform Guidance requirements regarding the process and controls used to administer federal awards. These changes address the issue of non-compliance by formally addressing the roles and responsibilities in writing of who at the agency is responsible for insuring that the Uniform Guidance is followed. The updated policy covers the areas of: allowable costs, cash management, procedures, and conflicts of interest. The new policy will be presented and reviewed for approval at the July 22nd, 2026, board meeting. We believe this corrective action plan will address the non-compliance and bring the agency into full compliance moving forward.
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