Corrective Action Plans

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REFERENCE: 2025-002 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient ...
REFERENCE: 2025-002 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient services being provided. Corrective Action Plan: Beginning in February 2025, Bailey-Boushay House Administrative staff send out upcoming Eligibility expirations occurring in the next 90 days to the Clinical Supervisor and Director of Outpatient Programs. The Clinical Supervisor forwards a list to each care manager/social worker for clients on their caseload. The Clinical Supervisor discusses the status of these updates during meetings with care manager/social worker. Notes are made on the caseload list to document the discussion of status. The Clinical Supervisor sends a list to the care management team for clients who are within 30 days of their expiration, in order to identify clients who may be out of contact or less engaged in the program. A note is provided with these clients' medications to remind them that they need to complete this eligibility update with a care manager or social worker. Quarterly and monthly emails of eligibility expirations are retained for documentation purposes. Person Responsible: Katie Hara, Director of Outpatient Programs – Bailey Boushay House Completion: February 2025
ELIZABETHTON CITY SCHOOLS Material Weakness JUNE 30, 2025 School Nutrition Fund 2025-001 Response and Corrective Action Plan Prepared by: Beth Wilson, Director of Finance, Elizabethton City Schools Person Responsible for Implementing the Corrective Action: Regina Isaacs, School Nutrition Coordinator...
ELIZABETHTON CITY SCHOOLS Material Weakness JUNE 30, 2025 School Nutrition Fund 2025-001 Response and Corrective Action Plan Prepared by: Beth Wilson, Director of Finance, Elizabethton City Schools Person Responsible for Implementing the Corrective Action: Regina Isaacs, School Nutrition Coordinator, Elizabethton City Schools Anticipated Completion of Corrective Action: May 31, 2025 Repeat Deficiency: No Planned Corrective Action: The student numbers were corrected and the USDA claims were adjusted before the end of the fiscal year. The School Nutrition Coordinator has been instructed to ensure that all students are counted correctly. Richard VanHuss Director of Schools
Management will continue to rely on their independent certified public accountant for assistance with their financial statement preparation.
Management will continue to rely on their independent certified public accountant for assistance with their financial statement preparation.
The District will be utilizing the consulting service with Julian & Grube in the future.
The District will be utilizing the consulting service with Julian & Grube in the future.
Audit Recommendation a) 2025-004: Full Service Community Schools-Assistance Listing No. 84.215J Grant NO. - S215J220016 Grant Period-Year ended June 30, 2025 the auditors recommend the District to implement a process that ensures an understanding of the grant revenue and expenditure recognition proc...
Audit Recommendation a) 2025-004: Full Service Community Schools-Assistance Listing No. 84.215J Grant NO. - S215J220016 Grant Period-Year ended June 30, 2025 the auditors recommend the District to implement a process that ensures an understanding of the grant revenue and expenditure recognition process. Regular reconciliations should be performed and monitored against the grant finance reports. Expenditures should be monitored against the approved budgets and overspent grants. Corrective Action Plan a) 2025-004: The District plans to ensure in-depth training on all grants the District receives and require regular reconciliations to the general ledger by using our financial program as well a spreadsheet at the end of every month and institute more oversight over the grant process. Implementation Date - June 30, 2026 Person Responsible for Implementation - Colleen Bellinger, School Business Manager
Views of Responsible Officials and Planned Corrective Actions: The District will implement a secondary review process for verifying, entering, and confirming the status of the free and reduced applications. Documentation will be maintained to indicate the individuals performing completion and second...
Views of Responsible Officials and Planned Corrective Actions: The District will implement a secondary review process for verifying, entering, and confirming the status of the free and reduced applications. Documentation will be maintained to indicate the individuals performing completion and secondary review of required steps to verify timeliness and accuracy of eligibility determination and reporting.
Condition: The School District does not properly review students’ institutional Student Information Records (ISIR) to determine that the student is eligible for federal student financial aid. Planned Corrective Action: The School District has implemented a formal review process to ensure all Institu...
Condition: The School District does not properly review students’ institutional Student Information Records (ISIR) to determine that the student is eligible for federal student financial aid. Planned Corrective Action: The School District has implemented a formal review process to ensure all Institutional Student Information Records (ISIRs) are accurately evaluated for student eligibility prior to awarding federal student aid. Staff have been trained on the new procedures, including resolving required data elements and confirming eligibility criteria. The District has also instituted periodic internal checks to ensure consistent and compliant ISIR review practices moving forward. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: October 2025
Condition: The School District relies on two-third party vendors to manage key financial aid systems, including student information, eligibility determinations, disbursement calculations, and reporting. During the audit period, the institution did not perform any oversight activities or testing to v...
Condition: The School District relies on two-third party vendors to manage key financial aid systems, including student information, eligibility determinations, disbursement calculations, and reporting. During the audit period, the institution did not perform any oversight activities or testing to verify the integrity, accuracy, or compliance of the systems managed by the vendor. There were no documented controls, service-level agreements, or monitoring procedures in place. Planned Corrective Action: The School District will establish formal oversight procedures for all third-party vendors supporting financial aid functions. This will include developing and maintaining service-level agreements, implementing documented monitoring and testing protocols, and conducting periodic reviews to verify system accuracy, data integrity, and federal compliance. Staff will be trained on these updated processes to ensure ongoing accountability. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: June 30, 2026
Condition: The School District is eligible to participate in Title IV federal student aid programs; however, it does not conduct an annual review of its institutional eligibility requirements nor maintain documentation supporting such assessments. Planned Corrective Action: The School District will ...
Condition: The School District is eligible to participate in Title IV federal student aid programs; however, it does not conduct an annual review of its institutional eligibility requirements nor maintain documentation supporting such assessments. Planned Corrective Action: The School District will implement an annual review process to verify its institutional eligibility for participation in Title IV programs. Procedures will include maintaining thorough documentation of all eligibility assessments and required approvals. Staff responsible for compliance will be trained on these updated requirements to ensure accurate and timely completion each year. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: June 30, 2026
Condition: The institution does not have a process or controls in place for a timely review of program eligibility, ECAR. Planned Corrective Action: The School District will establish a formal process to ensure timely and documented reviews of program eligibility in accordance with federal requireme...
Condition: The institution does not have a process or controls in place for a timely review of program eligibility, ECAR. Planned Corrective Action: The School District will establish a formal process to ensure timely and documented reviews of program eligibility in accordance with federal requirements. Staff will be trained on the new procedures, and the School District will implement internal controls to monitor program eligibility on a regular schedule. These steps will help ensure ongoing compliance and accurate determinations moving forward. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: June 30, 2026
Condition: The institution did not reimburse students with credit balances within 14 days of the balance being posted to their student ledger. Planned Corrective Action: The School District will strengthen its procedures to ensure all student credit balances are identified and refunded within the re...
Condition: The institution did not reimburse students with credit balances within 14 days of the balance being posted to their student ledger. Planned Corrective Action: The School District will strengthen its procedures to ensure all student credit balances are identified and refunded within the required 14-day timeframe. Staff will receive training on the updated process, and the District will implement regular monitoring to verify timely issuance of refunds going forward. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: June 30, 2026
Condition: The institution’s policy maintains that any unchased check must be returned to the State of Colorado after the financial statement year-end to the Great Colorado Payback program and does not include a carve-out for uncashed Title IV aid checks. Planned Corrective Action: The School Distri...
Condition: The institution’s policy maintains that any unchased check must be returned to the State of Colorado after the financial statement year-end to the Great Colorado Payback program and does not include a carve-out for uncashed Title IV aid checks. Planned Corrective Action: The School District will revise its policy to ensure uncashed Title IV aid checks are returned to the U.S. Department of Education in accordance with federal regulations, rather than to the State of Colorado. The updated policy will include a specific carve-out for Title IV funds, and staff will be trained on the revised procedures to ensure accurate handling and timely returns. Contact Person Responsible for corrective action: Lisa Bollers Anticipated Completion Date: June 30, 2026
Condition: The School District does not calculate or process any post-withdrawal disbursements for students that have withdrawn from the institution. Planned Corrective Action: The School District has implemented procedures to ensure post-withdrawal disbursements are calculated and processed in acco...
Condition: The School District does not calculate or process any post-withdrawal disbursements for students that have withdrawn from the institution. Planned Corrective Action: The School District has implemented procedures to ensure post-withdrawal disbursements are calculated and processed in accordance with federal Return of Title IV (R2T4) requirements. Staff have been trained to identify eligible students, complete the required calculations, and issue timely notifications and disbursements. The School District will also conduct periodic reviews to ensure that all post-withdrawal disbursements are consistently met. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: October 2025
Condition: The School District did not report the status changes of certain students to the NSLDS in an accurate and timely manner during the fiscal year. Planned Corrective Action: The School District will update its procedures to ensure all student status changes are reported to NSLDS accurately a...
Condition: The School District did not report the status changes of certain students to the NSLDS in an accurate and timely manner during the fiscal year. Planned Corrective Action: The School District will update its procedures to ensure all student status changes are reported to NSLDS accurately and within required federal timelines. Staff responsible for reporting will be retrained on the updated process and monitoring requirements. The School District will also implement a periodic internal review to verify the timely and accurate submission of information going forward. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: June 30, 2026
Condition: The School District did not utilize the cost of attendance when determining the maximum amount of aid a student is eligible to receive. The School District also does not maintain updated cost of attendance calculations for its programs. Planned Corrective Action: The School District will ...
Condition: The School District did not utilize the cost of attendance when determining the maximum amount of aid a student is eligible to receive. The School District also does not maintain updated cost of attendance calculations for its programs. Planned Corrective Action: The School District will implement procedures to ensure the cost of attendance (COA) is used when determining each student’s maximum eligible aid in accordance with federal requirements. The District will also develop and maintain updated COA calculations for all programs and review them annually. Staff will be trained on these processes to ensure accurate and compliant aid determinations moving forward. Contact Person Responsible for corrective action: Mary Cooper Anticipated Completion Date: June 30, 2026
Condition: The School Districts awarded aid to students using the full-time, three-quarter time, half-time, etc, schedule and improperly recorded students under a credit program versus appropriately recording them under a clock hour program, for which students would have been considered full-time in...
Condition: The School Districts awarded aid to students using the full-time, three-quarter time, half-time, etc, schedule and improperly recorded students under a credit program versus appropriately recording them under a clock hour program, for which students would have been considered full-time in their enrollment status if they did not attend less than half-time. Planned Corrective Action: The School District has revised its policies to ensure students in clock-hour programs are correctly classified and awarded according to federal requirements. As a result, we are now awarding full aid to all eligible students based on proper enrollment status determinations. Staff have been retrained on the updated procedures to ensure ongoing compliance. Contact Person Responsible for corrective action: Amy Beruan Anticipated Completion Date: November 2025
The South Central Cooperative Direcctor, Kristi Hilzendeger, is the contact person responsible for the corrective action plan for this finding. This finding is due to the size of the South Central Cooperative, which precludes staffing at a level sufficient to provide an ideal environment for interna...
The South Central Cooperative Direcctor, Kristi Hilzendeger, is the contact person responsible for the corrective action plan for this finding. This finding is due to the size of the South Central Cooperative, which precludes staffing at a level sufficient to provide an ideal environment for internal controls. The Cooperative has developed policies to help monitor the lack of segregatin of duties, but due to the size of the Cooperative it is not feasible, or fiscally responsible to implement anything else at this time. The Cooperative will continue to follow the controls currently in place.
The Cornbelt Educational Cooperative Business Manager, Pamela Selken is the contact person responsible for the corrective action plan for this finding. This finding is due to the limited number of staff employed in the Cooperative's business office. Staffing the office at an efficient and financiall...
The Cornbelt Educational Cooperative Business Manager, Pamela Selken is the contact person responsible for the corrective action plan for this finding. This finding is due to the limited number of staff employed in the Cooperative's business office. Staffing the office at an efficient and financially feasible level precludes the hiring of enough personnel to provide an ideal environment for the Internal controls. The Administration and Advisory Board is aware of the weakness in internal controls and will continue to develop policies and procedures and provide compensating controls to reduce the risk. We will also communicate this concern with our Board of Directors. The Cornbelt Educational Cooperative did adopt an Internal Controls and Procedures policy on March 13th, 2018 that does address many of these issues, and would ask for consideration reflecting this implementation. This finding will be an ongoing process, requiring continued analysis of processes and procedures in order to minimize the risk.
Department of Education – Direct Programs ALN # 84.268, 84.063, 84.007, 84.033 Student Financial Assistance Cluster – Special Tests and Provision – Disbursement on Behalf of Students Finding Summary: Two students were identified who were not awarded the full amount of Pell for which they were qualif...
Department of Education – Direct Programs ALN # 84.268, 84.063, 84.007, 84.033 Student Financial Assistance Cluster – Special Tests and Provision – Disbursement on Behalf of Students Finding Summary: Two students were identified who were not awarded the full amount of Pell for which they were qualified. Both students were registered in the summer session. Responsible Individual: Director of Financial Aid Corrective Action Plan: The College will implement a control process to ensure all semesters are properly identified and taken into account when creating a financial aid package for students. An evaluation will be done to ensure that no students who are eligible for Pell are precluded from receiving it. Anticipated Completion Date: Spring 2026
Department of Education – Direct Programs ALN # 84.268, 84.063, 84.007, 84.033 Student Financial Assistance Cluster – Special Tests and Provision – Disbursement on Behalf of Students Finding Summary: During the review of the calculation of student disbursements, a student was noted whose awards exce...
Department of Education – Direct Programs ALN # 84.268, 84.063, 84.007, 84.033 Student Financial Assistance Cluster – Special Tests and Provision – Disbursement on Behalf of Students Finding Summary: During the review of the calculation of student disbursements, a student was noted whose awards exceed the unmet needs. This over award that was created was in the form of non-Title IV scholarships. Responsible Individual: Director of Financial Aid Corrective Action Plan: The Office of Financial Aid is refining and validating the process for monitoring unmet need and potential over-awarding. The College will put extra effort on ensuring that this situation does not re-occur and ensure that all staff are following the established process to evaluate unmet need. Anticipated Completion Date: Fall 2025
Department of Education – Direct Programs ALN # 84.268, 84.063, 84.007, 84.003 Student Financial Assistance Cluster – Cash Management and Reporting Finding Summary: During the review of the reconciliation process, it was noted that only the month of January was reconciled as required by the DOE. The...
Department of Education – Direct Programs ALN # 84.268, 84.063, 84.007, 84.003 Student Financial Assistance Cluster – Cash Management and Reporting Finding Summary: During the review of the reconciliation process, it was noted that only the month of January was reconciled as required by the DOE. The school is required to reconcile funds received from G5 with actual disbursement records submitted to COD. The school is required to account for any differences between the DOE’s records and the school’s financial and business records. Responsible Individuals: Director of Financial Aid and Director of Finance Corrective Action Plan: The College will implement a process that requires regular reconciliation of funds received with disbursement records submitted to COD. This reconciliation will be reviewed by both the Director of Financial Aid and the Director of Finance to ensure the records are reconciled. Anticipated Completion Date: Fall 2025
Federal Agency Name: Department of Education – Direct Programs ALN #84.268, 84.063, 84.007, 84.033 Student Financial Assistance Cluster – Special Tests and Provisions – Returns to Title IV Finding Summary: During the review of the return to Title IV funds, there were eleven instances out of thirty i...
Federal Agency Name: Department of Education – Direct Programs ALN #84.268, 84.063, 84.007, 84.033 Student Financial Assistance Cluster – Special Tests and Provisions – Returns to Title IV Finding Summary: During the review of the return to Title IV funds, there were eleven instances out of thirty in which the Title IV funds to be returned were not calculated and returned if required within the 45-day maximum timeframe allowed. The R2T4 calculations for fall 2024 were not performed until February 2025. Responsible Individual(s): Director of Financial Aid Corrective Action Plan: This finding was due to the turnover of key personnel in the financial aid office during the academic year. Staffing in the office is currently stable and properly trained on regulations and the timing requirements and calculation of Return to Title IV. College is developing and refining a process to review and return Title IV funds in a timely manner. The calculations for subsequent semesters have been made in a timely manner. Anticipated Completion Date: Fall 2025
Finding 1167592 (2025-001)
Material Weakness 2025
MATERIAL WEAKNESSEs, 2025-001 - PROCUREMENT There is a material weakness identified in the audit that The District does not have the necessary internal controls over compliance and does not appear to have understanding or knowledge of the contract requirements for service contracts. Corrective Actio...
MATERIAL WEAKNESSEs, 2025-001 - PROCUREMENT There is a material weakness identified in the audit that The District does not have the necessary internal controls over compliance and does not appear to have understanding or knowledge of the contract requirements for service contracts. Corrective Action: Central Office Staff and Staff responsible for Federal Grants and Programs will familiarize themselves with and implement the proper procedures and requirements for service contracts and procurement methods to ensure it meets the requirements in the District Policy and Federal Procurement requirements. Anticipated Completion Date: January 31, 2026
Finding Number: 2025-002 Planned Corrective Action: Claims reimbursement will be inspected monthly by a separate person from who is inputting the data to ensure accurate filing of meals served. If discrepancies are discovered, the district will maintain support for the numbers that are submitted to ...
Finding Number: 2025-002 Planned Corrective Action: Claims reimbursement will be inspected monthly by a separate person from who is inputting the data to ensure accurate filing of meals served. If discrepancies are discovered, the district will maintain support for the numbers that are submitted to DEW. Anticipated Completion Date: 12/31/2025 Responsible Contact Person: Jared M Bunting, SFO
Condition: All management agent duties should be performed timely. Action Plan: Please see below the new process regarding hiring additional staff and turnover at Community Action Program Belknap-Merrimack Counties Inc. Due to lack of management, it is understood the importance of having staff train...
Condition: All management agent duties should be performed timely. Action Plan: Please see below the new process regarding hiring additional staff and turnover at Community Action Program Belknap-Merrimack Counties Inc. Due to lack of management, it is understood the importance of having staff training on a regular basis to ensure management and compliance duties can be performed adequately. Community Action Program Belknap-Merrimack Counties Inc. plans to improve the standards of employee training and will be hosting quarterly trainings on employee responsibilities, performance, and areas for improvement. This includes HUD trainings and keeping up to date on any new HUD policies and procedures. We understand the importance of a well-trained staff. We are committed to our performance and adhering to HUD standards while implementing policies to follow for continuous improvement. As of December 2025 this department is fully staffed, if for some reason we become not fully staffed in the coming year, I will hire a temp agency to help in the interim of being full staffed again. Completion Date: 6/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
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