Corrective Action Plans

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Name of Auditee: Central Falls Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: September 30, 2025 CAP Prepared by: Bridgett Duquette, Executive Director Phone: (401) 727-9090 (A) Current Finding on the Schedule of Findings and Questioned Costs (1) Finding 20...
Name of Auditee: Central Falls Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: September 30, 2025 CAP Prepared by: Bridgett Duquette, Executive Director Phone: (401) 727-9090 (A) Current Finding on the Schedule of Findings and Questioned Costs (1) Finding 2025-001 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendations, please see below for action taken. (b) Action taken - The Authority will submit all required documentation to HUD. (c) Planned implementation date of corrective action - Completed by September 30, 2026.
Moving forward, the Chamber will use an employee’s timesheet to bill wages to federal awards. When preparing reimbursement requests, the staff will calculate the wage amount that is equal to the number of hours each employee self-attested to working to the federal grant by coding the hours on their ...
Moving forward, the Chamber will use an employee’s timesheet to bill wages to federal awards. When preparing reimbursement requests, the staff will calculate the wage amount that is equal to the number of hours each employee self-attested to working to the federal grant by coding the hours on their timesheet for the applicable pay periods. If a true-up of wage expenses is done at any time during the cycle of the federal grant, the Chamber will maintain adequate documentation (the employee timesheets) to indicate how the true-up was calculated. The calculation provided by the staff will be reviewed by the Executive Director prior to the reimbursement request being submitted to the granting agency.
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Organization concurs that the reserve for replacement account is underfunded as of September 30, 2025. S3800-130 Response Indicator Agree S3800-140 Completion Date June 10, 2026 S3800-150 Response The Organi...
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Organization concurs that the reserve for replacement account is underfunded as of September 30, 2025. S3800-130 Response Indicator Agree S3800-140 Completion Date June 10, 2026 S3800-150 Response The Organization funded $816 to the reserve for replacements account. S3800-160 Contact Person First Name Carl S3800-180 Contact Person Last Name Marquette, Jr.
The Band has developed and initiated a procedure to subject all employees with access to vulnerable populations to be subjected to background investigations. The Band has instituted these procedures; however, they were initiated post the September 30, 2025 financial statements. OMB will continue to ...
The Band has developed and initiated a procedure to subject all employees with access to vulnerable populations to be subjected to background investigations. The Band has instituted these procedures; however, they were initiated post the September 30, 2025 financial statements. OMB will continue to monitor this process in a quarterly review with Human Resources.
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Control Procedures • Verify costs fall within grant period prior to posting Review Controls • Require supervisory approval Monitoring • Quarterly compliance testing
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Control Procedures • Verify costs fall within grant period prior to posting Review Controls • Require supervisory approval Monitoring • Quarterly compliance testing
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Documentation • Maintain at least three comparable rent analyses Review • Require supervisory approval prior to lease execution Training • Train staff on HUD requirements Monitorin...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Documentation • Maintain at least three comparable rent analyses Review • Require supervisory approval prior to lease execution Training • Train staff on HUD requirements Monitoring • Perform quarterly compliance reviews
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-002 AL Numbers: 93.837 Program: National Heart, Lung and Blood Institute Correction Action: Brown Health management concurs with this finding. We have already initiated re-training at the department level. For fiscal year 2026, we wil...
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-002 AL Numbers: 93.837 Program: National Heart, Lung and Blood Institute Correction Action: Brown Health management concurs with this finding. We have already initiated re-training at the department level. For fiscal year 2026, we will perform a detailed review of all salaries charged to federal grants to ensure there is no salary over the cap. Additionally, we will review automated control enhancements within our ERP system where possible to assist in recognizing compliance rules and/or enhance monitoring controls where possible. Contacts: Stephen Almonte, Vice President and Corporate Controller Salmonte3@brownhealth.org Bharat Ramratnam, MD, Senior Vice President of Research BRamratnam@brownhealth.org Planned Completion Date: October 31, 2026
Contact Person Emajean Hanson-Ford, Executive Director Corrective Action Plan The Authority has reviewed their procedures for performing and documenting follow up of HQS inspections to ensure compliance moving forward. Planned Completion Date for CAP December 31, 2026
Contact Person Emajean Hanson-Ford, Executive Director Corrective Action Plan The Authority has reviewed their procedures for performing and documenting follow up of HQS inspections to ensure compliance moving forward. Planned Completion Date for CAP December 31, 2026
2025-001 Special Test & Provisions – Contract Rent Adjustment Corrective Action: Currently, we are reviewing scheduling priorities to be able to submit the budget within the mandated time.. Proposed Completion Date: April 9, 2026 Contact Person: Dasil Thomas-Williams, Director of Financial Affairs T...
2025-001 Special Test & Provisions – Contract Rent Adjustment Corrective Action: Currently, we are reviewing scheduling priorities to be able to submit the budget within the mandated time.. Proposed Completion Date: April 9, 2026 Contact Person: Dasil Thomas-Williams, Director of Financial Affairs Telephone Number: (340) 772-4099 ext. 106
Type of Finding: Significant Deficiency in Internal Control Over Financial Reporting Criteria or Specific Requirement: County management should be aware if the need to have adequate policies and procedures in place for timely reimbursement requests for highway projects. Condition: Policies and proce...
Type of Finding: Significant Deficiency in Internal Control Over Financial Reporting Criteria or Specific Requirement: County management should be aware if the need to have adequate policies and procedures in place for timely reimbursement requests for highway projects. Condition: Policies and procedures in place for timely reimbursement requests will ensure that the County is receiving funds it is owed. In addition, this will ensure there are no cash flow shortages and increase opportunities for investment earnings. Cause: The County had one highway project for which costs were incurred in October and November 2024, and the related reimbursement was submitted and approved in June 2025. Possible Effect: By submitting untimely reimbursement requests, the County is not receiving funds it is owed in a timely manner, which has the potential to cause cash flow shortages. Repeat Finding: No. Recommendation: We recommend County management review internal controls currently in place and design and implement procedures to request reimbursements in a timelier fashion and to submit requests for reimbursements on at least a quarterly basis. Views of Responsible Officials: There is no disagreement with the audit finding. The County will implement procedures to ensure timely submission of reimbursement requests. Anticipated Completion Date: December 31, 2026.
Finding Reference Number: 2025-05 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented r...
Finding Reference Number: 2025-05 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented review controls over financial reporting. The Organization will take corrective action to strengthen internal control documentation, reduce reliance on informal processes, and ensure that information prepared by third-party service providers is reviewed and approved by management before use in quarterly reporting, annual reporting, the SEFA, and the financial statements. l. The Organization will update and maintain a fom1al policies and procedures manual that documents key accounting, grant management, financial reporting, and SEFA preparation processes. The manual will identify responsible positions, required approvals, review procedures, supporting documentation requirements, and backup responsibilities. Management will also evaluate current duties and implement additional segregation of duties where practical. Where staffing limitations prevent full segregation, compensating review controls will be documented and performed by management. 2. Management will document the established review process for all quarterly and annual reports prepared by third-party service providers. This review will include reconciliation to internal accounting records, verification of significant assumptions and supporting schedules, and evidence of management approval prior to submission or inclusion in the financial statements. 3. Finance personnel will be cross-trained on critical accounting, grant reporting, and SEFA responsibilities to ensure continuity of operations if key employees are unavailable or leave the Organization. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding Reference Number: 2025-02 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented r...
Finding Reference Number: 2025-02 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented review controls over financial reporting. The Organization will take corrective action to strengthen internal control documentation, reduce reliance on informal processes, and ensure that information prepared by third-party service providers is reviewed and approved by management before use in quarterly reporting, annual reporting, the SEFA, and the financial statements. 1. The Organization will update and maintain a formal policies and procedures manual that documents key accounting, grant management, financial reporting, and SEFA preparation processes. The manual will identify responsible positions, required approvals, review procedures, supporting documentation requirements, and backup responsibilities. Management will also evaluate current duties and implement additional segregation of duties where practical. Where staffing limitations prevent full segregation, compensating review controls will be documented and performed by management. 2. Management will document the established review process for all quarterly and annual reports prepared by third-party service providers. This review will include reconciliation to internal accounting records, verification of significant assumptions and supporting schedules, and evidence of management approval prior to submission or inclusion in the financial statements. 3. Finance personnel will be cross-trained on critical accounting, grant reporting, and SEFA responsibilities to ensure continuity of operations if key employees are unavailable or leave the Organization. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to incorrect participant meal coding and reimbursement classifications. Management has implemented the following corrective actions: 2...
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to incorrect participant meal coding and reimbursement classifications. Management has implemented the following corrective actions: 2 4 Provide refresher training to all staff responsible for determining and entering participant eligibility classifications. Develop written procedures outlining eligibility determination requirements and reimbursement coding standards. Conduct periodic internal audits of participant eligibility classifications to identify and correct errors timely. Maintain documentation of training attendance and ongoing monitoring activities. Responsible Party Sonja Williams and Site Coordinators Expected Completion Date September 30, 2026
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to missing participant eligibility documentation maintained by operating sites. Management has implemented the following corrective ac...
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to missing participant eligibility documentation maintained by operating sites. Management has implemented the following corrective actions: 1. Establish standardized procedures requiring all operating sites to submit enrollment forms and Income Eligibility Forms prior to reimbursement claims being submitted. 2. Develop a monitoring checklist to verify that all required participant documentation is collected, complete, and retained. 3. Require monthly compliance reviews of participant files for each operating site. 4. Provide additional training to site administrators regarding CACFP eligibility documentation and retention requirements. Responsible Party Jeff Reynolds and Sonja Williams Expected Completion 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 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.
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