Corrective Action Plans

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Management has implemented controls to ensure that all students receiving only failing grades ("all F") at the end of the semester are evaluated for potential R2T4 calculations.
Management has implemented controls to ensure that all students receiving only failing grades ("all F") at the end of the semester are evaluated for potential R2T4 calculations.
As of August 2025, management has implemented controls to monitor student enrollment statuses and ensure the timeliness and accuracy of NSLDS reporting.
As of August 2025, management has implemented controls to monitor student enrollment statuses and ensure the timeliness and accuracy of NSLDS reporting.
As of August 2025, management has implemented controls to monitor student enrollment statuses and ensure the timeliness and accuracy of NSLDS reporting.
As of August 2025, management has implemented controls to monitor student enrollment statuses and ensure the timeliness and accuracy of NSLDS reporting.
Monitoring of federal compliance information by management and the Board of Education will continue at the District. The District will conduct a documented review of monthly claim reports.
Monitoring of federal compliance information by management and the Board of Education will continue at the District. The District will conduct a documented review of monthly claim reports.
2025-005 - Material Weakness and Material Noncompliance - Allowable Costs Condition: Federal revenues and expenses reported on the Schedule of Expenditures of Federal Awards should only include eligible expenses that occurred within the current fiscal year. Corrective Action Plan: The Village experi...
2025-005 - Material Weakness and Material Noncompliance - Allowable Costs Condition: Federal revenues and expenses reported on the Schedule of Expenditures of Federal Awards should only include eligible expenses that occurred within the current fiscal year. Corrective Action Plan: The Village experienced some staff turnover in the prior fiscal year. In addition, the Village has not historically been subject to single audits, which created some challenges with the preparation of the Schedule of Expenditures of Federal Awards. Going forward, the Village has a better understanding of the requirements for completing the Schedule.
Recommendation: Management should review and update internal controls over reporting requirements to prevent untimely submissions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management reviews reporting deadli...
Recommendation: Management should review and update internal controls over reporting requirements to prevent untimely submissions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management reviews reporting deadlines to ensure timely submissions. Name(s) of the contact person(s) responsible for corrective action: Judy Thomas, CFO Planned completion date for corrective action plan: June 2025
Views of Responsible Officials and Planned Corrective Actions Clearinghouse reports are from the college’s student information system (SIS). During FY24, the finding stems from a student’s withdrawal, which was promptly processed and entered in the SIS. However, the system categorized the student as...
Views of Responsible Officials and Planned Corrective Actions Clearinghouse reports are from the college’s student information system (SIS). During FY24, the finding stems from a student’s withdrawal, which was promptly processed and entered in the SIS. However, the system categorized the student as "less than half-time” because the student received a passing grade in a course for which the student was exempted after passing a proficiency test. The SIS did not update the student status to 'withdrawn' until the semester ended, which was more than 60 days after the withdrawal date. To remedy this issue, the college’s Business Office now maintains an online spreadsheet listing withdrawn students outside the SIS that is updated whenever a student withdraws from the college. The list has been shared with the personnel responsible for the Clearinghouse reports and the Financial Aid Coordinator. Personnel will monitor the withdrawal listing and verify that all withdrawn students are accurately categorized in the Clearinghouse report from the SIS before completing the submission. After reviewing the FY25 finding, we discovered that the student attended in the spring 2025 semester but withdrew during the college’s drop/add period. By default, the SIS removes students who withdraw during drop/add from the Clearinghouse report.We have confirmed that Welch is unable to modify data or correct errors in the SIS report submitted to the Clearinghouse.Action Taken/Planned To address these problems, which ultimately stemmed from the limitations of Clearinghouse reporting by the college’s SIS, Welch has taken the following steps: 1. Clearinghouse reporting responsibilities have transitioned to a full-time, onsite employee in the Provost’s Office. 2. When preparing Clearinghouse reports and to help with identifying any errors before submitting the report, the employee will continue to monitor the withdrawn students listing maintained by the college’s Business Office, as outlined in the steps taken with the FY24 finding. 3. Welch plans to engage with its SIS and explain the reporting issues and limitations to determine if the SIS can help the college resolve the reporting limitations with its system. 4. To minimize the possibility of students being omitted from any Clearinghouse report, the employee responsible for the Clearinghouse report will submit an initial report to Clearinghouse on the first day of each term (fall, winter, spring, summer), followed by submitting reports on the mandatory reporting dates, as given by Clearinghouse. 5. The employee responsible for Clearinghouse reporting and the college’s Financial Aid Coordinator will collaborate before and after each Clearinghouse submission, and once the submission data is reported to NSLDS by Clearinghouse, the Financial Aid Coordinator will review all withdrawn students to confirm their NSLDS status is correct. If not, she will manually update the student’s NSLDS status to ensure accuracy. Anticipated Completion Date/Date Completed: November 6, 2025
Special Tests and Provisions: Enrollment Reporting – Federal Direct Student Loan Program, Assistance Listing Number 84.268; June 30, 2025 Award Year; U.S. Department of Education Condition Enrollment information, including the effective date of separation from the institution, must be accurately rep...
Special Tests and Provisions: Enrollment Reporting – Federal Direct Student Loan Program, Assistance Listing Number 84.268; June 30, 2025 Award Year; U.S. Department of Education Condition Enrollment information, including the effective date of separation from the institution, must be accurately reported to NSLDS within 30 days whenever attendance changes for a student, unless a roster will be submitted within 60 days. May 2025 graduates were reported to NSLDS outside of the maximum 60-day window. Corrective Actions Ellucian has since released a patch to address the known defect, and it has been successfully deployed by the University. Additionally, the University will continue to monitor subsequent submissions to NSC where errors were initially noted, to ensure status changes have been transmitted by the NSC in a timely manner to NSLDS. Responsible Official: Taylor Horner, University Registrar Completion Date: August 2025
Finding Number: 2025-005 Federal Program, Assistance Listing Number and Name: ALN 93.914, Department of Health and Human Services (HHS), HIV Relief Project Grants Condition: Original Finding Description: A lack of effective controls resulted in noncompliance with federal payment requirements, specif...
Finding Number: 2025-005 Federal Program, Assistance Listing Number and Name: ALN 93.914, Department of Health and Human Services (HHS), HIV Relief Project Grants Condition: Original Finding Description: A lack of effective controls resulted in noncompliance with federal payment requirements, specifically for payments made to subrecipients. Contact Person Responsible for Corrective Action / Anticipated Completion Date: Denise Fair Razo Regina Greear Terri Daniels Anticipated completion date: March 2026 Planned Corrective Action: The three payments made were paid one to two days after the 30 day reimbursement requirement. The City will review its subrecipient payment terms and implement additional processes to help ensure compliance with federal payment requirements.
FINDING: FINANCIAL REPORTING – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Finding Type: Material Weakness in Compliance and Internal Control over Compliance Finding No. 2025-002 Recommendation: Management should implement procedures to ensure an accurate schedule of expenditures of federal awards wi...
FINDING: FINANCIAL REPORTING – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Finding Type: Material Weakness in Compliance and Internal Control over Compliance Finding No. 2025-002 Recommendation: Management should implement procedures to ensure an accurate schedule of expenditures of federal awards with a corresponding reconciliation to the accrual basis trial balance. It is recommended that management establish and enforce review and approval procedures related to the schedule of expenditures of federal awards and the accrual basis trial balance. Responsible Official: Anthony D’Agostino, CEO Corrective Action Plan: The Organization acknowledges the importance regarding the accuracy of the schedule of expenditures of federal awards and corresponding reconciliation to the accrual basis trial balance. The Organization is taking steps to ensure the accuracy and completeness of the schedule of expenditures of federal awards. The Organization will also consider the employment of additional personnel with suitable knowledge, skills, and experience to contribute to the functions of the finance department. Planned completion date for corrective action plan: Fiscal year 2026
Significant Deficiency Item 2025-006 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 During ...
Significant Deficiency Item 2025-006 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we noted that LBUCC conducted quarterly internal audit reviews of fifty (50) samples self-pay patients to review for sliding fee discount determination. However, we noted that the findings or exceptions identified in the quarterly internal audit review remained uncorrected. Recommendation: We recommend that LBUCC establish a process for communicating, investigating and correcting all internal audit findings or exceptions on a timely manner. Additionally, we recommend that management identify the potential cause of such findings or exceptions and that necessary corrective actions be taken to address such cause. For example, LBUCC may conduct periodic training of all employees involved in the patient intake and screening process. Action Taken: The internal audit process has been redesigned and expanded to include weekly reviews and all exceptions/errors will be corrected and the cause determined. Additional training will be provided with the expectation that the exceptions/errors will reduce going forward. Effectivity Date: This will be fully implemented by 1/31/2026
Material Weakness Item 2025-005 -Activities Allowed and Una/lowed Costs - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 Dur...
Material Weakness Item 2025-005 -Activities Allowed and Una/lowed Costs - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we noted that LBUCC charged salaries to the Section 330 grant based on pre-determined allocations or budget rather than actual hours worked. LBUCC utilized timesheets that reflect the allocations as its time and effort documentation. Recommendation: We recommend that LBUCC implement a time and effort reporting system that tracks actual hours worked on each program or grant. We recommend that they require supervisors to review and approve the actual time spent on grant activities and that such review and approval be documented. Action Taken: LBUCC will implement a time and effort reporting system to include a semi-annual certification for all employees funded by the HRSA 330 grant and a time card reporting system for those funded by multiple grants. Effectivity Date: Time and effort reporting will be implemented in January 2026 and fully in place by 1/31/2026
Significant Deficiency Item 2025-004 - Reporting - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 LBUCC did not maintain doc...
Significant Deficiency Item 2025-004 - Reporting - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 LBUCC did not maintain documentation evidencing management's review of the Federal Financial Report (SF-425) prior to submission. Although the reports were submitted timely, there were no indication of formal review procedures to validate the accuracy, completeness, or consistency of reported financial data with the accounting records. Recommendation: We recommend that LBUCC establish and implement a formal review process over the Federal Financial Report (SF-425); we also recommend that evidence of the review be documented and approval be kept on file. Action Taken: Process in place where Director of Accounting will prepare the Federal Financial Report (SF-425) and the Chief Financial Officer will review and document approval which will be kept on file. Effectivity Date: Process was implemented 12/1/2025
Material Weakness Item 2025-002 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8HCS46163-03-01 During our a...
Material Weakness Item 2025-002 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8HCS46163-03-01 During our audit, we noted that LBUCC did not properly determine the sliding fee discount provided to certain eligible patients based on information provided during the patient registration process. Additionally, we could not ascertain if the sliding fee discount provided to certain eligible patients were correct as LBUCC did not maintain documentation of the proof of income of those eligible patients. Recommendation: We recommend that LBUCC conduct training of all of its personnel who are involved in determining and applying the sliding fee scale of patients. We also recommend LBUCC to maintain complete and auditable documentation supporting each patient's eligibility for sliding fee discount. Action Taken: Eligibility was provided additional training which included training on a tool to assist them in determining the proper sliding fee discount. Effectivity Date: Training was held on October 28, 2025, and the tool to assist them was reviewed and provided at that time and implemented immediately thereafter.
Finding #2025-002 – Significant Deficiency and Other Noncompliance – Reporting. Applicable federal program: U. S. Department of Health and Human Services, Assistance Listing #93.959, Passed through Texas Health and Human Services Commission, All contracts, Contract years: 09/01/23 – 08/31/24 and 09/...
Finding #2025-002 – Significant Deficiency and Other Noncompliance – Reporting. Applicable federal program: U. S. Department of Health and Human Services, Assistance Listing #93.959, Passed through Texas Health and Human Services Commission, All contracts, Contract years: 09/01/23 – 08/31/24 and 09/01/24 – 08/31/25. Condition and context: In our testing of a sample of monthly billings and quarterly reports from throughout the fiscal year, we noted that reports were not being submitted within the required timelines for several reporting periods. Management communicated their delays to Texas Health and Human Services Commission (THHS), and their plan to rectify the delays. Phoenix Houses of Texas were able to file all delayed quarterly reports and monthly billings prior to June 30, 2025. THHS has approved all the delayed monthly billings and quarterly reports. Recommendation: Re-emphasize internal controls over timely grant billing and reporting to comply with grant contracts. Planned corrective action: All outstanding billings were subsequently submitted and billings are now current and submitted in accordance with required timelines. Corrective actions implemented include updates to Finance Department policies and procedures to formalize month-end closing and billing timelines and to strengthen oversight and monitoring controls. These changes ensure that billing and reporting are performed on a timely and ongoing basis. Responsible officer: Drew Dutton, CEO and Anunoy Mou, Finance Director. Estimated completion date: Completed September 2025.
Significant Deficiency Finding: 2025-001 Certification of Tenants Criteria and Condition The grant agreement requires ECS to (1) maintain complete tenant files in the San Francisco HMIS ONE System with hard-copy eligibility documents; (2) apply changes to tenant rent portions based on City and Count...
Significant Deficiency Finding: 2025-001 Certification of Tenants Criteria and Condition The grant agreement requires ECS to (1) maintain complete tenant files in the San Francisco HMIS ONE System with hard-copy eligibility documents; (2) apply changes to tenant rent portions based on City and County of San Francisco Department of Homelessness and Supporting Housing (HSH) notifications; and (3) perform required initial, annual, and interim recertifications under the Housing First program model. We noted instances where tenant files did not contain complete eligibility documentation and/or where required recertifications or updates to tenant rent portions were not performed or documented in accordance with the grant requirements. Context ECS provides rental assistance under the program described in Appendix A-2, which requires full documentation of tenant eligibility and strict adherence to rent-portion updates and recertification timelines. Of our 31 selections, we noted 6 instances where homelessness verification was missing, 6 instances where the rent portions based on HSH notifications were incorrect and 10 instances where the recertifications were not completed for the grant period under audit. Questioned Cost There are no questioned costs regarding this finding. Cause The exceptions result from inconsistent file maintenance and monitoring procedures, including insufficient review over documentation completeness and timeliness of recertifications. The issues were centered on tenant files managed by a third-party service provider. Effect Incomplete tenant files and untimely recertifications increase the risk of noncompliance with grant requirements and may result in incorrect tenant rent portions being charged or insufficient support for program eligibility. Repeat Finding This finding is not a repeat finding. Recommendation We recommend that ECS enhance its documentation and monitoring processes with its third-party property managers by implementing a standardized tenant file checklist, conducting periodic supervisory reviews to confirm that all eligibility documents and recertifications are completed and retained, and establishing a tracking process to ensure tenant rent portions are updated promptly based on HSH notifications. View of responsible officials Management agrees with the recommendation. Corrective Action Planned ECS has taken and will continue to take the following steps in the 2026 fiscal year to correct this deficiency. Step 1: Resources ECS began addressing Certificate of Tenancy errors with the hiring an Associate Chief of Real Estate and Asset Management in August, a Director of Property Management in October and a Property Management Compliance Manager in September. Step 2: Best Practices ECS has hired a consulting firm to correct Certificate of Tenancy errors at its one of its sites and will apply the best practices learned to all the affiliate and master lease sites. In addition, ECS has put together policies and procedures and has offered training to both ECS and subcontracted staff on Certificate of Tenancy. ECS will continue to offer compliance training as it takes over property management across all Master Lease sites and the affiliate portfolio. Step 3: Take control of property management Replace outsourced property management with ECS staff to better control Tenant documentation at all master lease and affiliate sites. Step 4: Quality and Compliance ECS has started in a few sites to review Tenant documentation and will expand this review to all sites across its entire portfolio. Implementation Date ECS will fully correct Certificate of Tenancy errors by June 30, 2026. Responsible Personnel The Chief Operating Officer and the Associate Chief of Real Estate and Asset Management.
2025-001 Reporting US Department of Education – AL #s10.553, 10.555, 10.559 and 10.582 Child Nutrition Cluster Condition: The District submitted monthly child nutrition reimbursement claims that contained inaccurate meal counts for multiple months during the fiscal year. Specifically, the District o...
2025-001 Reporting US Department of Education – AL #s10.553, 10.555, 10.559 and 10.582 Child Nutrition Cluster Condition: The District submitted monthly child nutrition reimbursement claims that contained inaccurate meal counts for multiple months during the fiscal year. Specifically, the District overstated reimbursable meal counts due to errors in including non-reimbursable meals served. Additionally, the claims were not subject to an independent review prior to submission to ensure accuracy and completeness. Name of Contact Person: Ann Berman, Business Manager Plan of Action: The District will revisit the internal control processes surrounding the grant reporting and reimbursement process to ensure meal count information submitted is within program requirements of Child Nutrition Cluster programs. In the event there are questions surrounding meal count and other information subject to reporting, the District will continue to rely on timely guidance from external governmental accounting consultants, the Oregon Department of Revenue, and the Oregon Department of Education.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
The Workforce Development Department (GuilfordWorks) experienced turnover in program service level staffing during FY 2025 along with certain periods of vacancies. Additional training related to federal grant accounting, particularly the reporting requirements for the Department of Labor, will be co...
The Workforce Development Department (GuilfordWorks) experienced turnover in program service level staffing during FY 2025 along with certain periods of vacancies. Additional training related to federal grant accounting, particularly the reporting requirements for the Department of Labor, will be conducted with program staff. Backup program staff are now in place in case of primary staff absences. Finance Department staff will also hold periodic discussions with GuilfordWorks staff to ensure that reporting deadlines are consistently being met timely.
Corrective Action Plan For the Year Ended June 30, 2025 Finding: 2025-003 Name of contact person: Corrective Action: Proposed Completion Date: Corrective actions for Finding 2025-003 also applies to State award findings. Section IV - State Award Findings and Questioned Costs Section III - Federal Aw...
Corrective Action Plan For the Year Ended June 30, 2025 Finding: 2025-003 Name of contact person: Corrective Action: Proposed Completion Date: Corrective actions for Finding 2025-003 also applies to State award findings. Section IV - State Award Findings and Questioned Costs Section III - Federal Award Findings and Questioned Costs Jessica Wall, Human Services Director and Marcy Mays, Assistant Human Services Director Training to include technical assistance related to all Single County Audit Findings from the most recent audit. This training included a powerpoint presentation that covered income calculations, resources, self-employment and how to document each of these. During this training, we covered toggling into each determination to check for validity and made it a requirement that each caseworker calculate income outside of the system, upload their own calcuations into NCFast and verify that the outside calculation matches that in the system. Operational Support Representative visited the agency to provide training on self-employment, unemployment, passalong, SSI cases and passalong. Internally, we have developed second-party spreadsheets per worker to be able to better track individual performance and training needs. Internal Training completed on 09/17/25. Operational Support Training was provided on 10/22/25. Supervisors will provide at least monthly training on any new policy updates or second-party findings. 131
Name of Responsible Individual: Matt Cooper, Student Financial Services Corrective Action: To strengthen compliance and ensure the accuracy of student aid eligibility determinations, we will enhance Liberty’s quality control (QC) measures within the federal verification process. Our primary goal is ...
Name of Responsible Individual: Matt Cooper, Student Financial Services Corrective Action: To strengthen compliance and ensure the accuracy of student aid eligibility determinations, we will enhance Liberty’s quality control (QC) measures within the federal verification process. Our primary goal is to minimize errors, improve consistency, and ensure all Financial Aid verification activities align with federal regulations and institutional policy. We will begin by implementing a more targeted QC process aimed at validating records of students who submitted subsequent tax documents. We will increase our verification QC selections of this particular population from 35% (current) to 60% (future) to verify data accuracy, documentation completeness, and adherence to ED’s Application and Verification Guide (AVG). Findings from these reviews will be used to identify training needs and process improvements. Staff training will be expanded to focus on federal verification requirements, common error trends, and documentation standards. Refresher trainings will be held with the entire verification processing team, and supplemental individual coaching will be provided on a monthly basis to address any specific issues identified through QC. We will also create reporting to ensure the percentage of reviews mentioned above is maintained by our QC workflow. Regular data analysis will help identify any systemic issues early, allowing for corrective actions to mitigate any compliance issues. By reinforcing staff training, system monitoring, and increased reviews, we will ensure that our federal verification process remains accurate, compliant, and student-centered. Anticipated Completion Date: February 2026
Views of responsible officials and planned corrective actions: The Board believes it has personnel who possess suitable skill, knowledge, or experience to oversee services the auditor provides in assisting with financial statement presentation which requires a lower level of technical knowledge than...
Views of responsible officials and planned corrective actions: The Board believes it has personnel who possess suitable skill, knowledge, or experience to oversee services the auditor provides in assisting with financial statement presentation which requires a lower level of technical knowledge than the competence required to prepare the financial statements, related footnote disclosures and SEFA in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP).
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