Corrective Action Plans

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Student Financial Aid Cluster – Assistance Listing No. Various Recommendation: We recommend that the University review their awarding procedures and implement procedures to ensure the Stafford loans are awarded within the annual and aggregate limits. Explanation of disagreement with audit finding: T...
Student Financial Aid Cluster – Assistance Listing No. Various Recommendation: We recommend that the University review their awarding procedures and implement procedures to ensure the Stafford loans are awarded within the annual and aggregate limits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: At the time the Subsidized Direct Loan was initially awarded, the student was classified as grade level one and was correctly awarded $3,500. Subsequently, the student’s grade level increased; however, the Direct Loan award was not adjusted accordingly. The Office of Financial Aid relies on email notifications to identify students with grade-level changes, and the notification for this student was inadvertently missed. In response to this error, the Office of Financial Aid implemented additional monitoring controls. A report was developed to identify all students with changes in grade level and is now generated and provided weekly by the Office of the Registrar to the Office of Financial Aid. A designated Financial Aid Advisor has been assigned responsibility for reviewing this report and adjusting Direct Loan awards as necessary to ensure accuracy. As an additional preventative measure, the Director of Financial Aid will verify student grade level and corresponding Direct Loan eligibility prior to disbursement. The Office of Financial Aid will also conduct periodic reviews to confirm that Direct Loan awards consistently and accurately align with students’ grade levels.
Student Financial Aid Cluster – Assistance Listing No. Various Recommendation: We recommend that the University implement a formal review process as it relates to withdrawn students to ensure R2T4 calculations are being performed accurately and timely. Explanation of disagreement with audit finding:...
Student Financial Aid Cluster – Assistance Listing No. Various Recommendation: We recommend that the University implement a formal review process as it relates to withdrawn students to ensure R2T4 calculations are being performed accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The withdrawal dates applied in the Return to Title IV (R2T4) calculations were based on the dates students were administratively withdrawn by the Office of the Registrar. Upon identification of the audit finding, the Office of Financial Aid conducted a comprehensive review of the affected R2T4 calculations and made the necessary corrections. Any balances resulting from these errors were subsequently written off. Additionally, the Director of Financial Aid completed a full file review for the applicable award year to assess the accurate inclusion of scheduled break days. During this review, two additional students were identified whose R2T4 calculations did not include the appropriate number of break days. The calculations for these students were corrected, and the resulting balances were written off. No further errors were identified. As part of the corrective action, the Office of Financial Aid has hired an additional Financial Aid Advisor dedicated to the review and completion of R2T4 calculations. Furthermore, the Director of Financial Aid has implemented a secondary review process for all completed R2T4 calculations to ensure accuracy and compliance. The Office of Financial Aid has also reviewed the Financial Aid Handbook and applicable Code of Federal Regulations (CFR) related to R2T4 calculations to reinforce adherence to regulatory requirements. Name(s) of the contact person(s) responsible for corrective action: Angel Faast and Laura Silva Planned completion date for corrective action plan: 12/17/2025
Finding No. 2025-001 - Replacement Reserve Deposits Planned Corrective Action - Management will ensure that required monthly deposits are brought current and kept current in the future. Anticipated Completion Date - June 30, 2026. As of December 2025, Sharon Ridge Expansion Corporation has made paym...
Finding No. 2025-001 - Replacement Reserve Deposits Planned Corrective Action - Management will ensure that required monthly deposits are brought current and kept current in the future. Anticipated Completion Date - June 30, 2026. As of December 2025, Sharon Ridge Expansion Corporation has made payments for deposits through August 2025. Responsible Contact Person - Donn Castonguay, Treasurer
Finding Number: 2025-002 Anticipated Completion Date: 10/07/2025 Responsible Contact Person: Katherine Miranda, University Registrar Kelly Burt, Assistant Registrar Records Management and Reporting Michele Bergman, Assistant Registrar, Records Management and Reporting Planned Corrective Action: The ...
Finding Number: 2025-002 Anticipated Completion Date: 10/07/2025 Responsible Contact Person: Katherine Miranda, University Registrar Kelly Burt, Assistant Registrar Records Management and Reporting Michele Bergman, Assistant Registrar, Records Management and Reporting Planned Corrective Action: The Offices of the Registrar and Admission Operations reviewed the case, reviewed the proper student record protocol, and added a reporting checkpoint to review for dually enrolled students before submitting enrollment reports to the National Student Clearinghouse (NSC). Once NSLDS is updated with NSC data, the Office of the Registrar will work with Office of Financial Aid to confirm NSLDS is accurate for the dually enrolled students.
Criteria or Specific Requirement: Subparts D and E of 2 CFR Part 200 require a nonfederal entity to establish written policies, procedures, and standards of conduct, including procedures to implement the cash management requirements of 2 CFR section 200.305, procedures that comply with the procureme...
Criteria or Specific Requirement: Subparts D and E of 2 CFR Part 200 require a nonfederal entity to establish written policies, procedures, and standards of conduct, including procedures to implement the cash management requirements of 2 CFR section 200.305, procedures that comply with the procurement standards of 2 CFR sections 200.318 through 200.326, and procedures for determining the allowability of costs in accordance with Subpart E of 2 CFR Part 200. Specifically, 2 CFR sections 200.430, 200.431, and 200.475 require written policies concerning compensation for personal services, fringe benefits, and travel costs, respectively. Views from Responsible Officials: Management agrees with the finding. Management has established written policies and procedures after yearend that were the policies and procedures followed during the year under audit and meets the requirements of Subparts D and E of 2 CFR Part 200. Contact Person: John Jacques Date of Completion: November 14, 2025
Corrective Action Plan Finding Number: 2025-002 – Return of Title IV Funds Controls Finding: There is no evidence of a control in place by the College to review Return of Title IV Fund calculations. Corrective Action Planned Given the size of the Financial Aid Office, the College will implement comp...
Corrective Action Plan Finding Number: 2025-002 – Return of Title IV Funds Controls Finding: There is no evidence of a control in place by the College to review Return of Title IV Fund calculations. Corrective Action Planned Given the size of the Financial Aid Office, the College will implement compensating internal controls to ensure R2T4 calculations are accurate, timely, and compliant with federal regulations. Effective immediately, the College will implement the following controls: 1. Standardized R2T4 Processing All R2T4 calculations will be performed using the Department of Education Common Origination & Disbursement (COD) system to ensure consistent application of federal formulas. Official withdrawal dates will be confirmed using Registrar records prior to calculation. 2. Independent Post-Calculation Review Each R2T4 calculation will be reviewed by an individual other than the preparer, where feasible, or through supervisory review when staffing is limited. The review will confirm the accuracy of withdrawal dates, days attended, calculation inputs, and Title IV funds included. 3. Coordination and Reconciliation The Office of Financial Aid will coordinate with Student Accounts to ensure R2T4 results are applied correctly to the student account and that returned funds are processed within required timelines. 4. Documentation and Retention Evidence of review, including reviewer initials and date, will be retained for each R2T4 calculation. A simple R2T4 review checklist or log will be maintained. 5. Ongoing Oversight The Director of Financial Aid will conduct periodic spot checks to ensure R2T4 calculations and reviews are completed accurately and timely. Responsible Official: De Rodrick Jonkins, Director of Financial Aid Anticipated Completion Date: Implemented effective August 1, 2025 Additional Context The Director of Financial Aid assumed the role effective April 1, 2025, after prior corrective actions had been identified. While formal independent review controls were not documented during the audit period, there were no identified R2T4 compliance issues, late returns, or calculation errors. The corrective actions above are intended to formalize review processes and further reduce compliance risk.
Corrective Action Plan Finding Number: 2025-001 – Enrollment Reporting Controls – Student Financial Aid Special Test Finding: There is no control in place by the College to review information submitted to NSLDS for student enrollment status changes. Corrective Actions Planned Given the size of the F...
Corrective Action Plan Finding Number: 2025-001 – Enrollment Reporting Controls – Student Financial Aid Special Test Finding: There is no control in place by the College to review information submitted to NSLDS for student enrollment status changes. Corrective Actions Planned Given the size of the Financial Aid Office, the College will implement compensating internal controls to ensure accurate and timely enrollment reporting while maintaining operational efficiency. Effective immediately, the College will implement the following controls: 1. Continued Use of the National Student Clearinghouse (NSC) The College will continue to rely on the National Student Clearinghouse as its third-party servicer for enrollment status reporting to NSLDS. 2. Independent Post-Submission Review On a monthly basis, the Office of Financial Aid will review NSC enrollment reporting confirmation files to verify that enrollment status changes were submitted to NSLDS accurately and within the required 60-day timeframe. This review will be performed by an individual other than the primary preparer, where feasible, or through supervisory review when staffing is limited. 3. Documentation and Retention Evidence of review, including reviewer initials and date, will be retained. A simple enrollment reporting review log will be maintained to document compliance. 4. Ongoing Oversight The Director of Financial Aid will conduct periodic spot checks to confirm controls are operating as intended. Responsible Official: De Rodrick Jonkins, Director of Financial Aid Anticipated Completion Date: February 1, 2026 Additional Context The Director of Financial Aid assumed the role effective April 1, 2025, after prior corrective actions had been initiated. While formal independent review controls were not documented during the audit period, there were no identified instances of late enrollment reporting or inaccurate enrollment status submissions to NSLDS. The corrective actions above are intended to formalize controls and ensure sustained compliance with federal requirements.
Recommendations: The District should put controls in place that require contractors performing contract work valued at more than $2,000 and paid with federal funds to submit the required payroll reports, per the Wage Rate Requirements, throughout the contract work. Action Taken: We agree with the re...
Recommendations: The District should put controls in place that require contractors performing contract work valued at more than $2,000 and paid with federal funds to submit the required payroll reports, per the Wage Rate Requirements, throughout the contract work. Action Taken: We agree with the recommendation. Our targeted implementation date is January 2026
Recommendations: The District should include infrastructure items in the current inventory system. Action Taken: We agree with the recommendation. Our targeted implementation date is January 2026.
Recommendations: The District should include infrastructure items in the current inventory system. Action Taken: We agree with the recommendation. Our targeted implementation date is January 2026.
Condition: The Commission was unable to send failed HQS inspection notices promptly to participants who needed to correct deficiencies. Planned Corrective Action: HCV will hire additional internal support for HQS inspections to work alongside external vendors and ensure timely updates/mailings/, and...
Condition: The Commission was unable to send failed HQS inspection notices promptly to participants who needed to correct deficiencies. Planned Corrective Action: HCV will hire additional internal support for HQS inspections to work alongside external vendors and ensure timely updates/mailings/, and closeouts are uploaded to the work management system, Yardi. Contact person responsible for corrective action: Felicia Burris, HCV Program Manager Anticipated Completion Date: 6/30/2026
Primary Health Care Corrective Action Plan – Sliding Fee Finding: During the External Financial Audit for FY 2025, it was determined that certain patients had received sliding fee discounts that were not consistent with the stated sliding fee discount categories under PHC’s policy. Action Step Lead ...
Primary Health Care Corrective Action Plan – Sliding Fee Finding: During the External Financial Audit for FY 2025, it was determined that certain patients had received sliding fee discounts that were not consistent with the stated sliding fee discount categories under PHC’s policy. Action Step Lead Support Due Date Update resource materials associated with sliding fee discounts and distribute to necessary staff. Provide training to necessary staff on sliding fee discount policy and any changes to discounts. Beth Frantum, CFO Revenue Cycle Director Patient Services Director March 2026 Develop and implement an internal review process to provide reasonable assurance that Slide calculations are accurate and EPIC reflects the correct amount expected for services. Beth Frantum, CFO Revenue Cycle Director Patient Services Director John Shaw, Director of Clinics April 2026
Payroll Administration concurs with the recommendation pertaining to the preparation, review, and approval of employee timesheets to ensure the accuracy and completeness of payroll records. Employee timesheets and payroll records are originated, reviewed, and retained at the respective work location...
Payroll Administration concurs with the recommendation pertaining to the preparation, review, and approval of employee timesheets to ensure the accuracy and completeness of payroll records. Employee timesheets and payroll records are originated, reviewed, and retained at the respective work locations. Therefore, Payroll Administration does not have direct access to these site-level records. To strengthen compliance, Payroll Administration will continue to provide targeted training and guidance to time reporters and time approvers on the timely review and approval of timesheets, the required time and effort certification, as well as the reconciliation of timesheet data with SAP entries. These topics will be reinforced during the monthly Time Reporter and Time Approver Virtual Office Hours. Furthermore, Payroll Administration will continue to issue periodic communications and disseminate the Best Practices Worksheet, which outlines key payroll compliance requirements, including adherence to payroll cut-off deadlines and reconciliation of timesheets and time entry in SAP. Payroll Administration remains committed to supporting District departments and school sites in maintaining full compliance with established payroll policies and procedures. Name: Araceli Pineda Title: Director, Payroll Administration Contact Information: araceli.pineda@lausd.net
The financial aid office is under new leadership as of January 1, 2025. During 2025, department leadership began its review of departmental policies and procedures, focusing on remediating compliance weaknesses within the department while moving toward best practice in federal and state aid delivery...
The financial aid office is under new leadership as of January 1, 2025. During 2025, department leadership began its review of departmental policies and procedures, focusing on remediating compliance weaknesses within the department while moving toward best practice in federal and state aid delivery. Department leadership has put structures in place at multiple points of potential failure to prevent inaccurate aid calculations. These structures include new policy and procedure documentation, enhanced optimization in the Banner system, staff training in multiple modalities including intradepartmental training, asynchronous independent training, off-site training, and a monthly reconciliation program with AVC’s fiscal office. We have also begun a system of cross training to ensure that expertise persists within the department during times of staffing changes, extended leaves of absence, and vacancies.
Finding 2025-001: During the year ended September 30, 2025, the Company loaned funds totaling $10,850 to two other Communities under common management and affiliated with the Sole Member of the Company to help fund operating shortfalls of the other Communities. Comments on the Finding and Each Recom...
Finding 2025-001: During the year ended September 30, 2025, the Company loaned funds totaling $10,850 to two other Communities under common management and affiliated with the Sole Member of the Company to help fund operating shortfalls of the other Communities. Comments on the Finding and Each Recommendation: Management and/or the Sole Member should reimburse the Company for the funds that were loaned to the two other Communities. If there are further operating shortfalls in the future, these should be funded by Management and/or the Sole Member and not borrowed from other Communities. Action(s) taken or planned on the finding: Management concurs with the finding and agrees with the recommendation. On November 7, 2025, Management deposited $10,850 into the Community's operating account. No further action is required.
Finding No: 2025-003 Condition: The District does not have an adequate review process in place for meal count claims prior to submission. Claims prepared by one individual are submitted without independent verification. As a result, the district reported an incorrect lunch count for January 2025. Th...
Finding No: 2025-003 Condition: The District does not have an adequate review process in place for meal count claims prior to submission. Claims prepared by one individual are submitted without independent verification. As a result, the district reported an incorrect lunch count for January 2025. This error appears to be isolated to January; however, it would likely have been prevented if a review process were in place. Plan: The District will implement a system in which meal count claims will have secondary approval by the CSBO. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Mark Orszula, CSBO
Condition & Criteria: For three aviation program students, cost of attendance calculations were based on expected high-cost courses, but actual enrollment differed, resulting in overstated costs and excess aid disbursement. Auditor’s Recommendation: Adjust cost of attendance based on actual courses ...
Condition & Criteria: For three aviation program students, cost of attendance calculations were based on expected high-cost courses, but actual enrollment differed, resulting in overstated costs and excess aid disbursement. Auditor’s Recommendation: Adjust cost of attendance based on actual courses attended and fees incurred. Corrective Action: The Financial Aid Department now verifies actual course enrollment prior to disbursement for specialized programs, ensuring accuracy and compliance. Beginning Winter term 2026, mid-term audits for the aviation program have been implemented to strengthen oversight. Additionally, policy updates now require real-time cost of attendance adjustments for all individualized programs to maintain consistency and alignment with federal regulations. Responsible Person: Director of Financial Aid, with support from Aviation Program Director. Anticipated Completion Date: Begin implementation immediately and accomplish full implementation by Spring 2026; ongoing monitoring.
The District will review the work performed by the individual preparing the reports before submission
The District will review the work performed by the individual preparing the reports before submission
A more robust procurement policy is being prepared to comply with Uniform Guidance section 200.320. Additional training will be provided to Department Heads and staff involved in the grant application and administration process.
A more robust procurement policy is being prepared to comply with Uniform Guidance section 200.320. Additional training will be provided to Department Heads and staff involved in the grant application and administration process.
Federal Agency Name: United States Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliation for the federal program ...
Federal Agency Name: United States Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliation for the federal program and there was no formal review of the balance in comparison to the required minimum reserve balance. Due to there being no formal review of the balance in comparison to the required minimum reserve balance, the reserve balance was underfunded as of June 30, 2025 in the amount of $17,486. Corrective Action Plan: We will implement additional control processes to ensure a formal review over the reserve fund reconciliation and a formal review of the balance in comparison to the required minimum reserve balance is completed by staff separate from the preparer. On November 28, 2025, the minimum reserve balance was fully funded at $358,800. Responsible Individual: Mandy Robinson, Administrator Anticipated Completion Date: 11/28/2025
Village of Moweaqua will include in future contracts
Village of Moweaqua will include in future contracts
CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 Identifying Number: Finding 2025-001 Identification of federal program: Federal Award Agency: Substance Abuse and Mental Health Services Administration Program Name and Federal Assistance Listing No.: Certified Community Behavioral Health Clinic Expans...
CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 Identifying Number: Finding 2025-001 Identification of federal program: Federal Award Agency: Substance Abuse and Mental Health Services Administration Program Name and Federal Assistance Listing No.: Certified Community Behavioral Health Clinic Expansion Grants – 93.696 Pass-Through Entity: not applicable, direct funding Pass-Through Award Numbers: not applicable, direct funding Criteria or specific requirement: Section 200.308 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) governs the revision of program plans. A recipient must request prior written approval from the federal agency entity when there is a disengagement from a project for more than three months, or a 25% reduction in time and effort devoted to the federal award. The terms and conditions of this award require that an evaluator be assigned to the program maintaining a 50% level of effort. Any changes to key personnel including level of effort involving separation from the project for any continuous period of three months or longer, or a reduction in time dedicated to the project of 25% or more requires prior approval and must be submitted as a postaward amendment in eRA Commons. Condition: The Certified Community Behavioral Health Clinic Expansion Grants require that a project evaluator devote 50% level of effort requirement to the program. During the fiscal year ended June 30, 2025, due to program personnel turnover, OhioGuidestone was not able to ensure that the required level of effort be maintained and did not obtain the required approvals maintained by the terms and conditions of the grant agreement. Cause: Due to program personnel turnover, OhioGuidestone was not able to ensure that the required level of effort was maintained for the fiscal year ended June 30, 2025. Effect or potential effect: A failure to comply with the terms and conditions of the grant agreement could result in material noncompliance. Questioned cost: None.Context: Due to staff turnover, the project evaluator position for the Four County grant was vacant during February and March 2025. To maintain continuity, the Organization temporarily assigned the project evaluator from the Cuyahoga County contract to cover these months because of her familiarity with the program. However, prior written approval for this change was not obtained as required by the grant agreement. A new project evaluator was hired for April through June 2025, but onboarding delays prevented full engagement until after year-end. As a result, the level-of-effort requirement was not met for February through June 2025. Recommendation: We recommend that the Organization review existing policies and procedures and make enhancements where appropriate to monitor compliance with level-of-effort requirements on a periodic basis and to ensure that the required approvals are obtained. Corrective Actions Taken or Planned: OhioGuidestone acknowledges and agrees with this finding. In addition to tracking the LOE on the shared monthly budget tracking report, we will include a copy of the NOA Special Terms for Key Personnel in the report. If the LOE falls below the required level, the Grant Manager will inform Program Leadership using the comments section of the shared workbook. The staff assigned to the comment will respond with reasoning and expected timeframe to have the position back up to the required LOE. We will evaluate the situation including timeframe and determine if prior approval and a post award amendment is necessary. In the case of staff termination, we will initiate the post award amendment, notify SAMHSA of the separation, and seek approval to deviate from the required LOE during the recruiting period. Upon hiring for the position, another post award amendment will be submitted notifying SAMHSA of the new staff. Grant Manager will host a meeting with all staff involved detailing the new process. Name of contact person responsible for corrective action: Joseph Ziegler, Chief Financial Officer Anticipated completion date: December 31, 2025
This is no disagreement with the finding. Management immediately began to review policies and procedures and implemented revised procedures during August of 2024.
This is no disagreement with the finding. Management immediately began to review policies and procedures and implemented revised procedures during August of 2024.
Name of auditee: B'nai B'rith Housing of New Haven, Inc. HUD auditee identification number: 017-EE029 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Linda Hamilton Position: Senior Vice President Telephone number: (860) 6...
Name of auditee: B'nai B'rith Housing of New Haven, Inc. HUD auditee identification number: 017-EE029 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Linda Hamilton Position: Senior Vice President Telephone number: (860) 646-6555 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding #2025-001: Comments on the Finding and Each Recommendation For the years ended June 30, 2024 and June 30, 2023, the Corporation did not submit the Data Collection Form (SF-SAC) to the Office of Management and Budget (OMB) as required by Uniform Guidance section 2 CFR 200.512. The Corporation should submit all future Data Collection Forms in the required time frame. Action(s) Taken or Planned on the Finding Agree. Management concurs with the recommendation and notes that the Data Collection Form will be submitted timely moving forward.
The City will ensure that all activity is recorded timely related to Federal Drug Forfeitures so that the Equitable Sharing Agreement and Certification can be completed within 60 days of the City’s fiscal year end.
The City will ensure that all activity is recorded timely related to Federal Drug Forfeitures so that the Equitable Sharing Agreement and Certification can be completed within 60 days of the City’s fiscal year end.
The City will work with its vendors and engineering/accounting personnel to ensure that invoices are submitted and paid as soon as possible following the end of each reporting period so that reporting deadlines to grantors are complied with in future periods.
The City will work with its vendors and engineering/accounting personnel to ensure that invoices are submitted and paid as soon as possible following the end of each reporting period so that reporting deadlines to grantors are complied with in future periods.
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