Corrective Action Plans

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Client Response: Since the identification of this in August 2025, our Clinical Manager has reviewed and audited every slide fee patient's information on a monthly basis. Additionally, the individual who has applied the majority of the incorrect discounts is no longer with the organization. Since thi...
Client Response: Since the identification of this in August 2025, our Clinical Manager has reviewed and audited every slide fee patient's information on a monthly basis. Additionally, the individual who has applied the majority of the incorrect discounts is no longer with the organization. Since this was also a finding from last year's audit, FY'23-24, as outlined in 2024-4 (pg.28), moving forward, our CFO will be handling the creation of the Slide Fee scale and will work with management and the Consultants to automate the system so errors rarely occur.
The fiscal year 2025 annual audit identified a material weakness in internal controls regarding documentation of procurement procedures required under federal or State awards, specifically related to suspension/debarment verification and sole-source justification. Public Library of Charlotte and Mec...
The fiscal year 2025 annual audit identified a material weakness in internal controls regarding documentation of procurement procedures required under federal or State awards, specifically related to suspension/debarment verification and sole-source justification. Public Library of Charlotte and Mecklenburg County Material Weakness Finding 2025-002 Corrective Action Plan: Because of the material weakness finding, the following actions have/will be taken: - When utilizing federal funds, the Library will properly document verification that vendors were not suspended or debarred prior to contract execution in accordance with Uniform Grant Guidance procurement standards. - The Library will ensure that all required documentation supporting sole source vendor selection is completed and retained in accordance with the Library’s procurement policy. Each action stated in the corrective action plan will be completed during and by the end of fiscal year 2026. Responsible Parties: Michael Boger, Deputy Finance Director Angie Myers, Interim CEO & Chief Financial and Administrative Officer (CFO)
Corrective Action Plan: The Authority will limit advancing funds from Federal Programs to allowable Fees only. The agency will collaborate with our accountants to locate additional sources of non-federal funds and plan to have the funds repaid to Public Housing during our fiscal year 2026.
Corrective Action Plan: The Authority will limit advancing funds from Federal Programs to allowable Fees only. The agency will collaborate with our accountants to locate additional sources of non-federal funds and plan to have the funds repaid to Public Housing during our fiscal year 2026.
Recommendation: We recommend that the District implement procedures and controls to ensure that only eligible students are included on the MARSS listing. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The ...
Recommendation: We recommend that the District implement procedures and controls to ensure that only eligible students are included on the MARSS listing. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to work on establishing procedures and controls to ensure that only eligible students are included on the MARSS listing. Official Responsible for Ensuring CAP: Tanner Spawn, Business Manager. Planned Completion Date for CAP: June 30, 2026.
Recommendation: We recommend that the District implement procedures and controls to ensure the journal entries are accurate before posting. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will ...
Recommendation: We recommend that the District implement procedures and controls to ensure the journal entries are accurate before posting. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to work on implementing procedures and controls to ensure all journal entries are reviewed and accurate before posting. Official Responsible for Ensuring CAP: Tanner Spawn, Business Manager. Planned Completion Date for CAP: June 30, 2026.
Recommendation: We recommend that the District implement procedures and controls to ensure that all paper applications are being reviewed. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will c...
Recommendation: We recommend that the District implement procedures and controls to ensure that all paper applications are being reviewed. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to work on establishing procedures and controls to ensure that all paper applications are being reviewed. Official Responsible for Ensuring CAP: Tanner Spawn, Business Manager. Planned Completion Date for CAP: June 30, 2026.
The District will implement a secondary review process for the nutrition reimbursement reports and will monitor the monthly financials to ensure revenue is reasonable based on meal counts.
The District will implement a secondary review process for the nutrition reimbursement reports and will monitor the monthly financials to ensure revenue is reasonable based on meal counts.
Management will review the claims list for completeness and accuracy before presenting the list to the board for approval.
Management will review the claims list for completeness and accuracy before presenting the list to the board for approval.
The District will implement a secondary review process for the nutrition reimbursement reports and will monitor the monthly financials to ensure revenue is reasonable based on meal counts.
The District will implement a secondary review process for the nutrition reimbursement reports and will monitor the monthly financials to ensure revenue is reasonable based on meal counts.
Management will review the claims list for completeness and accuracy before presenting the list to the board for approval.
Management will review the claims list for completeness and accuracy before presenting the list to the board for approval.
Condition: The Intermediate School District (ISD) did not have internal controls in place to ensure that all the expenditures included in the quarterly claims for reimbursement were allowable. Planned Corrective Action: The ISD will review the process used by the local districts to report quarterly ...
Condition: The Intermediate School District (ISD) did not have internal controls in place to ensure that all the expenditures included in the quarterly claims for reimbursement were allowable. Planned Corrective Action: The ISD will review the process used by the local districts to report quarterly expenditures for the Administrative Outreach program. We will then create a process that ensures that the local districts provide supporting documentation that allows us to monitor the quarterly submission amounts for accuracy. Contact person responsible for corrective action: Chris Frank, Asst. Superintendent for Business Anticipated Completion Date: 1/31/2026
Auditor Description of Condition and Effect: During testing, we identified 1 instance out of 40 disbursement selections tested in which the District was unable to provide supporting documentation for charges incurred under the grant. Additionally, we noted 15 instances out of 40 selections tested wh...
Auditor Description of Condition and Effect: During testing, we identified 1 instance out of 40 disbursement selections tested in which the District was unable to provide supporting documentation for charges incurred under the grant. Additionally, we noted 15 instances out of 40 selections tested where the District could not provide evidence of review and approval for grant expenditures. Finally, we identified 3 instances out of 40 selections tested where the hours reported on timesheets did not agree with the hours charged to the grant. The District’s failure to maintain supporting documentation for certain grant expenditures, provide evidence of review and approval, and accurately report time charged to the grant increases the risk of noncompliance with federal requirements under 2 CFR Part 200. These deficiencies create an increased risk of questioned costs which could ultimately lead to disallowed costs and the potential repayment of grant funds to the granting agency. Additionally, inaccurate reporting and weak internal controls diminish the reliability of financial information submitted to the grantor, reduce accountability, and heighten the risk of errors or fraudulent activity. Auditor Recommendation: We recommend that the District review its written policies and procedures over federal awards to ensure that controls are in place that will require that all expenditures for either payroll or disbursements have the appropriate documentation and evidence of review and approval prior to payment. Corrective Action: The District will review its written policies and procedures over federal awards to ensure that all expenditures have the appropriate documentation and evidence of review and approval prior to payment. Responsible Person: Maria Gistinger, Interim Chief Financial Officer Anticipated Completion Date: June 30, 2026
Enforce the organization's R2T4 refund calculation proceedures
Enforce the organization's R2T4 refund calculation proceedures
2025 – 001: Period of Performance Federal Program CFDA # 14.872 Capital Fund Program Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: Recommendation: It is recommended the Authority review all of the policies in place relating to the obligation of capital progra...
2025 – 001: Period of Performance Federal Program CFDA # 14.872 Capital Fund Program Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: Recommendation: It is recommended the Authority review all of the policies in place relating to the obligation of capital programs to ensure that funding is properly obligated and expended within the required time frame. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in response to finding: The PHA will proactively seek clarification from HUD when guidance is unclear or when operational challenges arise. The PHA remains committed to full compliance with HUD requirements and values its collaborative relationship with HUD. The Authority appreciates the guidance and technical assistance provided and will continue to work proactively to ensure clarity, transparency, and accountability moving forward. Name of the contact person responsible for corrective action: Jacque Sikes, Executive Director Planned completion date for corrective action plan: January 2026
2025-003 – UNALLOWABLE COSTS Corrective Action Plan: We have implemented a new policy that requires the Superintendent to review and sign-off on all outgoing EFT and ACH payments. We have implemented a new policy that requires the Superintendent to review and sign-off on all bank statements. Respons...
2025-003 – UNALLOWABLE COSTS Corrective Action Plan: We have implemented a new policy that requires the Superintendent to review and sign-off on all outgoing EFT and ACH payments. We have implemented a new policy that requires the Superintendent to review and sign-off on all bank statements. Responsible Party(ies): • Superintendent and Board of Education Anticipated Completion Date: June 30, 2026
New depository agreements have been executed between the Housing Agency and the banks. Signature from HUD is pending.
New depository agreements have been executed between the Housing Agency and the banks. Signature from HUD is pending.
U.S. Department of Housing and Urban Development: The Housing Authority of the County of Contra Costa respectfully submits the following corrective action plan for the year ended March 31, 2025. Auditor: Novogradac and Company, LLP Certified Public Accountants 1144 Hooper Avenue Suite 203 Toms River...
U.S. Department of Housing and Urban Development: The Housing Authority of the County of Contra Costa respectfully submits the following corrective action plan for the year ended March 31, 2025. Auditor: Novogradac and Company, LLP Certified Public Accountants 1144 Hooper Avenue Suite 203 Toms River, New Jersey 08753 The findings from the March 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings – Federal Award Program Audit Finding 2025-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Number: 14.871, 14.879 and 14.EHV Noncompliance – E. Eligibility – Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 11,032 units. Of a sample size of sixty-nine (69) tenant files, the following was noted: - Declaration of Section 214 Status form was missing in one (1) file - HUD-9886 Authorization for Release of Information was missing in six (6) files - Lead based paint form was missing in one (1) file - HUD-50058 Form applicable to the audit period was missing in seven (7) files Our sample size is statistically valid. Known Questioned Costs: $168,325 Cause: There is a material weakness in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement.. Views of responsible officials and planned corrective action: We agree with the Auditor’s observations on the inspection of the tenant files and will implement internal control procedures that will ensure compliance of federal regulations. HACCC identified two primary causes of the deficiency and has outlined corrective measures to address them. Firts, HACCC recognized the need for improved training on supervisory tools used to monitor recertification deadlines. Management was retrained in November 2025 on the use of WorkQueue oversight tools and on conducting daily team stand-up meetings to reinforce production goals. Key performance indicators from these meetings flow to management reports and executive leadership for ongoing monitoring. Second, HACCC'S HCV program partnered with Paul Edwards Management and Consulting (PEM) on May 1, 2024. This partnership provided HACCC's HCV program with technical assistance and coverage of positions which had remained vacant from 2021 until recently. Ingrid Layne, Director of Assistance Housing, will be responsible to implement this corrective action by March 31, 2026.
Finding 2025-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public and Indian Housing Program Federal Catalog Numbers: 14.850 Noncompliance – E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: Yes Material weakness in Inte...
Finding 2025-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public and Indian Housing Program Federal Catalog Numbers: 14.850 Noncompliance – E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: Yes Material weakness in Internal Control over Compliance for Eligibility Finding 2025-003 (continued) Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit and the Authority failed to properly calculate the tenant's rent payments using documentation from third party income verification. Context: There are approximately 834 units. Of a sample size of twenty three (23) tenant files, the following was noted: Original Applications were missing in thirteen (13) files. Citizenship Declarations were missing in five (5) files. Verification of income was missing in eight (8) files. The Authority also failed to properly calculate the rent payments of four (4) tenants by not utilizing documentation from third party income verification. Our sample size is statistically valid. Cause: There is a material weakness in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files and the calculation of rent. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure eligibility compliance with the Uniform Guidance and the compliance supplement. Authority's response: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Views of responsible officials and planned corrective action: Ms. Irma Gorham, Executive Director is responsible to remedy the deficiency by March 31, 2026.
Finding 2025-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Number: 14.871 & 14.EHV Noncompliance – E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: Yes Material weakness in Int...
Finding 2025-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Number: 14.871 & 14.EHV Noncompliance – E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: Yes Material weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). Finding 2025-001 (continued) Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit and the Authority included income that was miscalculated during the annual recertification. Context: Of a sample size of thirty-seven (37) tenant files, the following information was unavailable for examination at the time of audit: • Original application was missing in one (1) file • Citizenship declaration was missing in one (1) file • Signed lease was missing in one (1) file • Verification of income was missing in four (4) files • HUD form 50058 was not timely filed for one (1) file In addition, three (3) tenants' annual recertifications (HUD-50058 form) included income that was miscalculated. Our sample size is statistically valid. Cause: There is a material weakness in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered and designed a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster program is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure eligibility compliance with the Uniform Guidance and the compliance supplement. Authority Response: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster Program to ensure that established internal control policies are being followed on a timely basis. Views of responsible officials and planned corrective action: Ms. Irma Gorham, Executive Director is responsible to remedy the deficiency by March 31, 2026.
Finding 2025-002 Child Nutrition Cluster #10.555 & #10.553 Condition: The District did not have internal control over compliance procedures designed and implemented for the compliance of Paid Lunch Equity requirements. Views of Responsible Officials: The district's Business Manager is the responsibl...
Finding 2025-002 Child Nutrition Cluster #10.555 & #10.553 Condition: The District did not have internal control over compliance procedures designed and implemented for the compliance of Paid Lunch Equity requirements. Views of Responsible Officials: The district's Business Manager is the responsible official for federal programs. The Business Manager stated that they understand and agree with the finding. Planned Corrective Action: A documented process will be designed and implemented for the review of the Paid Lunch Equity calculation. Person Responsible for Corrective Action Plan: Business Manager Anticipated Completion Date: January 2, 2026
Condition: The Organization did not review period end reimbursement requests for costs that had been expended and requested in prior months. The lack of proper review resulted in the Organization charging duplicate costs of $95,294. Planned Corrective Action: The CFO maintains a payout tracker which...
Condition: The Organization did not review period end reimbursement requests for costs that had been expended and requested in prior months. The lack of proper review resulted in the Organization charging duplicate costs of $95,294. Planned Corrective Action: The CFO maintains a payout tracker which is updated every time a vendor payout is made and tracks that payment to the reimbursement request and the final payment by the pass-through agency. This process ensures that a payout is not included in a payout request multiple times. The Staff Accountant also maintains a tracker of all reimbursement requests to track with the program budgets and for inclusion in the MIP accounting system. In addition, new personnel are involved in the process with a more formal approval and authorization process implemented. The Organization’s staff has communicated these duplicate requests to the appropriate personnel at the granting agency and are coordinating the repayment of the excess funds as determined by the granting agency. Contact person responsible for corrective action: Tom Sakos, Chief Financial Officer, and Jenny Cuitiva, Accounting Manager Anticipated Completion Date: May 1, 2025 for implementing controls and November 30, 2025 for communicating with the granting agency.
2025-005 – Medicaid – Allowable Activities and Costs The District is aware of the student’s receiving benefits need to have their billed services included in their IEPs. Responsible Officials – Beth Munson, Director of Business Services and Lisa Blochwitz, Director of Student Services Anticipated Co...
2025-005 – Medicaid – Allowable Activities and Costs The District is aware of the student’s receiving benefits need to have their billed services included in their IEPs. Responsible Officials – Beth Munson, Director of Business Services and Lisa Blochwitz, Director of Student Services Anticipated Completion Date – The District intends to work towards resolving this finding for the following year.
Views of Responsible Officials and Corrective Action Plan The District submits the file with the required enrollment information to the National Student Clearinghouse (NSC) two weeks after the start of each term and subsequently on a monthly basis. Part of the reporting process includes running SFRT...
Views of Responsible Officials and Corrective Action Plan The District submits the file with the required enrollment information to the National Student Clearinghouse (NSC) two weeks after the start of each term and subsequently on a monthly basis. Part of the reporting process includes running SFRTMST, a baseline process in Ellucian Banner, the District’s Enterprise Resource Planning system, to calculate or update a student’s enrollment time status, which is the date when a change occurred in the enrollment of a student due to either registering in a class(es) or withdrawing from a class(es). The enrollment time status date is included in the enrollment file submitted to NSC. NSC then submits the enrollment information to the National Student Loan Data System (NSLDS). The discrepancy identified for the nine students was between a withdrawal date in Banner versus the enrollment time status date reported to NSC/NSLDS, which was the Banner calculated date. Because of the timing of when the SFRTMST process was ran, some students’ enrollment time status date did not match the registration activity date/enrollment effective date in Banner. After conducting research using the Ellucian Customer Center, the District identified a resolution to address this issue and has already implemented it for Fall 2025. To ensure that the students’ enrollment time status date reported to NSC/NSLDS matches the students’ effective date of their registration activity in Banner, the District activated the Calculate Time Status (Indicator) in SOATERM, a Banner setup, for Fall 2025 and will do so for all terms moving forward. Per Ellucian, when this indicator is set to “Y” a dynamic time status calculation will take place. The District verified that this process works. The issue has been resolved. In addition, the dates for the nine students were corrected in NSLDS. It is important to note that this issue has had no financial impact on the District. The students have been disbursed the correct amount of financial aid. The calculation of financial aid to be disbursed is not based on the enrollment dates reported to NSC and NSLDS.
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