Corrective Action Plans

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Reference Number 2025-002: Corrective Action Plan: Regarding internal controls over the FFATA (Federal Funding Accountability and Transparency Act) reporting, although no formal approval record could be provided, program staff reported that FFATA reports were verbally reviewed through one-on-one dis...
Reference Number 2025-002: Corrective Action Plan: Regarding internal controls over the FFATA (Federal Funding Accountability and Transparency Act) reporting, although no formal approval record could be provided, program staff reported that FFATA reports were verbally reviewed through one-on-one discussions. As recommended, the County will revise its internal FFATA reporting procedures to require that all FFATA submissions undergo a documented review and approval by an individual who is independent of the preparer. The procedures will be updated to require that the reviewer’s name, title, date of review, and confirmation of the reviewer’s approval be maintained in the program’s electronic records. The County will implement a standardized approval workflow—either through a designated electronic form, checklist, or approval routing mechanism—to ensure consistency across departments. Additionally, staff responsible for FFATA preparation and review will receive updated guidance and training on the new documentation requirements, The County will also evaluate opportunities to integrate this control into existing financial reporting and monitoring structures overseen by Housing and Community Development Services (HCDS) teams, to ensure consistent application of the updated approval requirements across reporting cycles. Anticipated Implementation Date: Updated procedures, workflow documentation, and staff training will be completed by June 30, 2026. Person Responsible: KELLY SALMONS, Deputy Director, Housing and Community Development Services
Student Financial Assistance Cluster– Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the College review current processes for reporting to NSLDS and implement procedures to ensure submissions are reported timely and accurately. Explanation of disagreement with aud...
Student Financial Assistance Cluster– Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the College review current processes for reporting to NSLDS and implement procedures to ensure submissions are reported timely and accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CSC utilizes National Student Clearinghouse (NSC) for NSLDS Reporting. The Registrar’s office is responsible for Enrollment Reporting. The four students with Reporting discrepancies are correctional students that do not have access to electronic forms. This population of students must submit paper requests and have them physically routed to the Registrar’s office for processing. The Enrollment and Reporting dates were in line; the discrepancy lies in the Program Enrollment date. The Registrar is researching if the student changed programs after their Enrollment dates. For the Enrollment Reporting date discrepancy outside the 60-day requirement, we reported the correct date to NSC. The Registrar has put in a ticket with NSC to see why they reported the Enrollment Date late. Name(s) of the contact person(s) responsible for corrective action: Current Registrar: Tosha Stout and Current Financial Aid Director: Tara Torres Planned completion date for corrective action plan: 6/30/26
Student Financial Assistance Cluster– Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and policies around reporting disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagre...
Student Financial Assistance Cluster– Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the College evaluate its procedures and policies around reporting disbursements to COD to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The late reporting was the result of a known FAFSA issue that began occurring with the 24/25 FAFSA Simplification and continues with the 25/26 FAFSA. The exception occurred when the student was not presented with the HS Completion Status question on the application. Students must self-certify they have a HS Diploma or Equivalent to be eligible for Federal Student Aid. CSC exported the origination to COD. COD approved the award, but CSC was unable to post the award to the student’s account because the HS Completion Status was blank. As soon as the student corrected her FAFSA, CSC posted the award and reported it to COD. The CSC FA office now receives a report with missing HS Completion Status each day and deletes federal awards until the issue is resolved preventing late COD Reporting. Name(s) of the contact person(s) responsible for corrective action: Current Financial Aid Director: Tara Torres OR Current Assistant Financial Aid Director: Tina Ballinger Planned completion date for corrective action plan: Completed
COMMONWEALTH OF PUERTO RICO AUTONOMOUS MUNICIPALITY OF VEGA BAJA Corrective Action Plan For the Fiscal Year Ended June 30, 2025 Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2024...
COMMONWEALTH OF PUERTO RICO AUTONOMOUS MUNICIPALITY OF VEGA BAJA Corrective Action Plan For the Fiscal Year Ended June 30, 2025 Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2024 – June 30, 2025 Fiscal Year: 2024-2025 Principal Executive: Hon. Marcos Cruz Molina, Mayor Contact Person: Mr. Edgardo Pérez, Department of Management, Administration and Budget Director Phone: (787)855-2500 Original Finding Number: 2025-004 Statement of Concurrence or Non concurrence: We concur with the findings. Corrective Action: The ACUDEN agency has not yet closed the budget year 2024-2025. Therefore, even though the contract has ended, the remaining reimbursement from the agency has not been received. Therefore, the full closing report cannot be completed until this final amount is received. As a corrective measure for finding 2025-005, the Sub Director of Finance will establish an internal control system in which the processes and compliance with the submission of accounting reports for federal programs, including Child Care, will be periodically monitored. Implementation Date: Fiscal Year 2026-2027. Responsible Person: José A. Mathews Maisonet Program Accountant
COMMONWEALTH OF PUERTO RICO AUTONOMOUS MUNICIPALITY OF VEGA BAJA Corrective Action Plan For the Fiscal Year Ended June 30, 2025 Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2024...
COMMONWEALTH OF PUERTO RICO AUTONOMOUS MUNICIPALITY OF VEGA BAJA Corrective Action Plan For the Fiscal Year Ended June 30, 2025 Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2024 – June 30, 2025 Fiscal Year: 2024-2025 Principal Executive: Hon. Marcos Cruz Molina, Mayor Contact Person: Mr. Edgardo Pérez, Department of Management, Administration and Budget Director Phone: (787)855-2500 Original Finding Number: 2025-003 Statement of Concurrence or Non concurrence: We concur with the findings. Corrective Action: During the past year, the Corrective Action Plan (PAC) has been implemented and expense reconciliation efforts have been ongoing. Currently, we are in the process of collecting all supporting documentation related to work performed for projects funded by FEMA. It is expected that the reconciliation of expenses will be completed over the next few quarters, and that expense reporting will continue during the quarters in which payments are made. Implementation Date: Fiscal Year 2025-2026. Responsible Person: José A. Torres Otero Program Accountant
Finding Number: 2025-001 Condition: The College did not update the student enrollment information for any of the students graduating in Fall of 2024. Planned Corrective Action: Lake Michigan College understands the significance of accurately reporting student enrollment statuses and will implement e...
Finding Number: 2025-001 Condition: The College did not update the student enrollment information for any of the students graduating in Fall of 2024. Planned Corrective Action: Lake Michigan College understands the significance of accurately reporting student enrollment statuses and will implement enhanced oversight controls. This includes the creation of a log that now documents file “receipts” from the National Student Clearinghouse. These report receipts are then reconciled to file submissions to ensure all files were received. Additionally, we have implemented a more overarching review that ensures all files are adequately processed by the National Clearinghouse. It is important to note the institution has corrected the files noted in the audit finding and all student records have now been updated to reflect accurate graduation and enrollment statuses. Contact person responsible for corrective action: Carrie Beukelman, Registrar Anticipated Completion Date: 03/01/2026
Condition: The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan: A second person (superintendent) compares the meal counts in the claim to the SDS daily meal co...
Condition: The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan: A second person (superintendent) compares the meal counts in the claim to the SDS daily meal count reports, monthly participation summary, eligibility rosters (free, reduced, paid) and USDA reimbursement rates. The reviewer will then sign and date a reconciliation sheet before submission. Management Response: The corrective action plan was discussed with the employee responsible for filing the claim, the business manager, and the superintendent. After discussion, the plan was approved by the superintendent.
The Screven County School System Nutrition Department will submit purchase order requests in YOSS, which is the digital Accounts Payable system utilized by the district. Requests will be reviewed for approval by the Director of Operations. If approved by the Director of Operations, the request will ...
The Screven County School System Nutrition Department will submit purchase order requests in YOSS, which is the digital Accounts Payable system utilized by the district. Requests will be reviewed for approval by the Director of Operations. If approved by the Director of Operations, the request will be sent through YOSS for the Superintendent's approval and then to bookkeeping to be ordered. When the items are received, accounts payable will send the invoice through YOSS for approval for payment to the Superintendent. This will provide a multiple layer to the approval process to ensure that procurement procedures are being followed.
Name of Contact Person: Tarsha Dudley, Executive Director. Corrective Action: Management will review the recertification process and plan to monitor recertifications. Proposed Completion Date: Immediately.
Name of Contact Person: Tarsha Dudley, Executive Director. Corrective Action: Management will review the recertification process and plan to monitor recertifications. Proposed Completion Date: Immediately.
The Agency will (1) clearly identify and communicate staff responsibilities for the preparation, review, and submission of required federal reports, (2) strengthen internal controls over reporting by implementing additional internal deadline reminders to ensure reports are completed and submitted pr...
The Agency will (1) clearly identify and communicate staff responsibilities for the preparation, review, and submission of required federal reports, (2) strengthen internal controls over reporting by implementing additional internal deadline reminders to ensure reports are completed and submitted prior to due dates, (3) establish procedures to monitor reporting deadlines based on applicable grant requirements and reporting periods, and (4) provide management oversight to confirm all required reports are reviewed, approved, and submitted timely. These actions are intended to address the delays in submitting required reports under the Head Start program and to help ensure ongoing compliance with federal reporting requirements.
2025-001 – Enrollment Reporting Federal Pell Grant Program; Federal Direct Student Loans – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and review regulations set by the Department of Education around NSLDS to ensure the University underst...
2025-001 – Enrollment Reporting Federal Pell Grant Program; Federal Direct Student Loans – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and review regulations set by the Department of Education around NSLDS to ensure the University understands the definitions for each enrollment information that gets reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Felician University agrees with the findings and will take the following steps to remedy the issues. First, we will contact the National Student Clearinghouse to evaluate our current reporting structure and make necessary changes to enhance our data output. Secondly, we will revisit our Leave of Absence and Withdrawal policies and procedures to ensure their alignment with NSLDS compliance standards. Management will monitor these issues internally and with periodic engagements with the National Student Clearinghouse during the year to ensure compliance. Name(s) of the contact person(s) responsible for corrective action: Nina Hernandez, Director of Registration and Records Planned completion date for corrective action plan: April 30th, 2026
Finding 2025-003 Student Financial Aid Cluster, CFDA # 84.063, 84.268 Condition: The College did not report the actual disbursement date that students receive the Direct Loan and/or Pell Funds to the COD system Corrective Action Plan: Objective: To ensure the Financial Aid office reports the actual ...
Finding 2025-003 Student Financial Aid Cluster, CFDA # 84.063, 84.268 Condition: The College did not report the actual disbursement date that students receive the Direct Loan and/or Pell Funds to the COD system Corrective Action Plan: Objective: To ensure the Financial Aid office reports the actual disbursement date the student receives the Direct Loan and/or Pell funds to the COD system. Corrective Actions: Management concurs with this finding. The College acknowledges that disbursement dates reported to COD reflected submission dates rather than actual student disbursement dates, resulting in inconsistencies. Corrective actions implemented as follows: 1. Definition Standardization 2. System Configuration & Process Update 1. Actual disbursement dates are captured at the transaction level 2. Data feeds into COD accurately once Financial Aid is converted to Ellucian 3. Reconciliation Controls 1. Monthly reconciliation between: 1. Student account ledger 2. COD system records 4. Quality Assurance Reviews 1. Supervisor approval required prior to COD reporting Timeline: Process corrections implemented in Fall 2025; Full compliance expected by June 30, 2026 Person(s) Responsible for Corrective Action Plan: Anahi Huerta, Director of Financial Aid, Phone: 312-922-1884
Finding 2025-002 Student Financial Aid Cluster, Assistance Listing # 84.063, 84.268 Condition: The College did not send changes in attendance levels of students, including students who graduated, withdrew, dropped out, or enrolled changes to the NSLDS within 60 days of the change. Corrective Action ...
Finding 2025-002 Student Financial Aid Cluster, Assistance Listing # 84.063, 84.268 Condition: The College did not send changes in attendance levels of students, including students who graduated, withdrew, dropped out, or enrolled changes to the NSLDS within 60 days of the change. Corrective Action Plan: Objective: To ensure the timely reporting of changes in attendance levels of students, including students who graduated, withdrew, dropped out, or enrolled, to the National Student Loan Data Center (NSLDS) within 60 days of the change. Corrective Actions: Management concurs with this finding. The College did not consistently report student status changes to NSLDS within the required 60-day timeframe due to inefficient tracking processes and system misalignment between internal records and reporting systems. Corrective actions implemented as follows: 1. Automated Tracking & Reporting Calendar 1. Established a compliance calendar with hard deadlines (<30 days internal target) 2. System Integration Improvements 1. Enhanced data alignment between: Ellucian Colleague, National Student Clearinghouse, and NSLDS 3. Accountability Structure 1. Assigned a designated compliance owner for NSLDS reporting 2. Introduced escalation protocols for missed deadlines 4. Monitoring & Reporting 1. Monthly compliance certification to senior leadership Timeline: Process corrections implemented in Summer 2025; Full compliance expected in Fall 2025 onward Person(s) Responsible for Corrective Action Plan: Anahi Huerta, Director of Financial Aid, Phone: 312-922-1884
We acknowledge the finding 2025-001 regarding the untimely reporting to the NSLDS and understand the importance of adhering to the prescribed reporting timelines to ensure that student loan and grant information is accurate and up-to-date. We take this matter seriously and are committed to rectifyin...
We acknowledge the finding 2025-001 regarding the untimely reporting to the NSLDS and understand the importance of adhering to the prescribed reporting timelines to ensure that student loan and grant information is accurate and up-to-date. We take this matter seriously and are committed to rectifying the situation as quickly as possible. Root Cause: It was discovered that the student records did not update correctly from the transmittal. Corrective Actions: - Transmit end of term file and degree verify file to National Student Clearinghouse (NSC). - After the file has been processed, we manually check each student record to ensure that the student's status is updated correctly. - After the next NSLDS report is processed by the NSC, we manually check each student record to ensure that the proper status has been reported to the NSLDS. Conclusion: We take the findings of the audit seriously and are committed to improving our processes and addressing the root causes of late reporting. The corrective actions outlined above are designed to prevent recurrence of this issue, ensure compliance with NSLDS reporting deadlines, and improve overall reporting accuracy and timeliness. Linda Fleischman Registrar PO Box 7323 (704) 406-4263 lfleischman@gardner-webb.edu
Corrective Action Plan: The College will implement a process to verify the enrollment update changes have taken effect on the NSLDS website. The registrar’s office will verify the student status updates for a sample size of 15% of the overall batch population for any given month’s transmission withi...
Corrective Action Plan: The College will implement a process to verify the enrollment update changes have taken effect on the NSLDS website. The registrar’s office will verify the student status updates for a sample size of 15% of the overall batch population for any given month’s transmission within the 60-day required timeframe. Timeline for Implementation of Corrective Action Plan: These corrective actions are being implemented in Spring 2026.
Finding Number: 2025-047 Planned Corrective Action: To strengthen internal controls, enhance record tracking, and ensure reconciliation of records within FFATA, the Agency has implemented the following measure: Subrecipient agreements are executed through the Division of Emergency Management Enterpr...
Finding Number: 2025-047 Planned Corrective Action: To strengthen internal controls, enhance record tracking, and ensure reconciliation of records within FFATA, the Agency has implemented the following measure: Subrecipient agreements are executed through the Division of Emergency Management Enterprise Solution (DEMES). The Agency has developed a new monthly report within DEMES that identifies all agreements executed within the preceding 30 days. The Office of Procurement and Contract Management will manually reconcile this report against FFATA entries to ensure Federal reporting requirements are met. Anticipated Completion Date: 4/1/2026 Responsible Contact Person: Tara Walters
Finding Number: 2025-025 Planned Corrective Action: DCF Revenue Management will collaborate with the Office of Contracted Client Services and Information Technology (IT) to address FFATA reporting deficiencies. DCF will evaluate and strengthen Post Award Notice (PAN) data management processes that s...
Finding Number: 2025-025 Planned Corrective Action: DCF Revenue Management will collaborate with the Office of Contracted Client Services and Information Technology (IT) to address FFATA reporting deficiencies. DCF will evaluate and strengthen Post Award Notice (PAN) data management processes that support FFATA reporting, reduce reliance on manual data entry where feasible, strengthen coordination between and enhance staff training on federal FFATA requirements to improve reporting accuracy and reporting controls. Improvements and enhancements to ensure timely notification of subaward executions and amendments will include: • Automated or system-based notification workflows will be implemented, where feasible, to reduce reliance on manual communication between Budget, Contract Managers, and Revenue Management. • Contract Administration will reinforce internal procedures requiring prompt submission of executed subawards and amendments by Contract Managers and their supervisors. • Targeted training will be provided to Contract Managers on FFATA reporting triggers, including distinctions between total subaward amounts and expenditures, to address the misunderstanding identified in the audit by a sub-office in Administration. DCF will also enhance and expand monitoring tools, maintain ongoing reporting training, and strengthen internal communication to ensure compliance with federal regulations and reduce the time between subaward issuance and reporting in FSRS (SAM.gov). The Department has set an implementation completion target date of September 30, 2026, for development, testing, approval, updating procedures, and training on reports and federal requirements. Anticipated Completion Date: 09/30/2026 Responsible Contact Person: Crystal Sims, Chief of Revenue Management
Finding Number: 2025-043 Planned Corrective Action: Supervisors will be required to submit an email for employees whose scope of work requires access to the Florida Ryan White Portal (FL RW Portal) with all required documents to a designated inbox. The email and forms will be evaluated and approved ...
Finding Number: 2025-043 Planned Corrective Action: Supervisors will be required to submit an email for employees whose scope of work requires access to the Florida Ryan White Portal (FL RW Portal) with all required documents to a designated inbox. The email and forms will be evaluated and approved before the user is added to the FL RW Portal. Additionally, the employee gaining access or having access removed, will be logged with a time stamp and signoff of the employee providing/removing access. The onboarding/offboarding instructions will instruct all supervisors to submit an email for separated employees within one business day of separation requesting access removal from the FL RW Portal. In addition, there will be a process added to conduct quarterly reviews of user access to ensure employees have appropriate access. Anticipated Completion Date: June 1, 2026 Responsible Contact Person: Chrystal Thompson
Finding Number: 2025-042 Planned Corrective Action: FAHCA added a comparison of MLR information with the annual audited financial report required under 42 CFR section 438.3(m) on the MLR Exhibit tab on the ASR template. MLR comparison was added on April 10, 2024, and plans were notified by email on ...
Finding Number: 2025-042 Planned Corrective Action: FAHCA added a comparison of MLR information with the annual audited financial report required under 42 CFR section 438.3(m) on the MLR Exhibit tab on the ASR template. MLR comparison was added on April 10, 2024, and plans were notified by email on April 17, 2024. The effective reporting date for the new MLR implementation went into effect on July 1, 2024. The 2024 audited ASR, issued in September 2025, includes MLR comparison. Anticipated Completion Date: Completed on September 1, 2025 Responsible Contact Person: Mercedes Bosque
Finding Number: 2025-041 Planned Corrective Action: FAHCA management will enhance controls to ensure that all identified overpayments are timely reported to CMS for refunding of overpayments on Form CMS-64 in accordance with Federal regulations. Anticipated Completion Date: December 31, 2026 Respons...
Finding Number: 2025-041 Planned Corrective Action: FAHCA management will enhance controls to ensure that all identified overpayments are timely reported to CMS for refunding of overpayments on Form CMS-64 in accordance with Federal regulations. Anticipated Completion Date: December 31, 2026 Responsible Contact Person: Kimberly Jordan
Finding Number: 2025-038 Planned Corrective Action: FDCF will evaluate its manual closure process and if necessary, make adjustments to ensure appropriate action is taken when a manual review is required. Anticipated Completion Date: December 31, 2026 Responsible Contact Person: Tera Bivens, Directo...
Finding Number: 2025-038 Planned Corrective Action: FDCF will evaluate its manual closure process and if necessary, make adjustments to ensure appropriate action is taken when a manual review is required. Anticipated Completion Date: December 31, 2026 Responsible Contact Person: Tera Bivens, Director of Programs & Policy Julie Reed, Chief of Policy
Finding Number: 2025-024 Planned Corrective Action: The Department shall review internal processes to identify mechanisms for documenting the deactivation of user access privileges. Anticipated Completion Date: 12/30/2026 Responsible Contact Person: Angela Carney, Audit & Compliance Consultant
Finding Number: 2025-024 Planned Corrective Action: The Department shall review internal processes to identify mechanisms for documenting the deactivation of user access privileges. Anticipated Completion Date: 12/30/2026 Responsible Contact Person: Angela Carney, Audit & Compliance Consultant
Finding Number: 2025-023 Planned Corrective Action: The Office of Information Technology Services (OITS) ACCESS application team that supports the FLORIDA system is in year four of a multi-year modernization initiative. By the end of 2027, all FLORIDA front-end functionality is expected to be availa...
Finding Number: 2025-023 Planned Corrective Action: The Office of Information Technology Services (OITS) ACCESS application team that supports the FLORIDA system is in year four of a multi-year modernization initiative. By the end of 2027, all FLORIDA front-end functionality is expected to be available through the ACCESS Management Portal, and staff will no longer have direct access to the FLORIDA mainframe. Given the current modernization progress and the planned elimination of direct mainframe access by the end of 2027, the Department acknowledges and accepts the residual risk during this transition. Anticipated Completion Date: 06/30/2028 Responsible Contact Person: Angela Carney, Audit & Compliance Consultant
Finding Number: 2025-035 Planned Corrective Action: FAHCA management will enhance reporting controls to ensure that all applicable CHIP subaward action information is timely reported in accordance with FFATA. Anticipated Completion Date: Completed Responsible Contact Person: Kimberly Jordan
Finding Number: 2025-035 Planned Corrective Action: FAHCA management will enhance reporting controls to ensure that all applicable CHIP subaward action information is timely reported in accordance with FFATA. Anticipated Completion Date: Completed Responsible Contact Person: Kimberly Jordan
Finding Number: 2025-033 Planned Corrective Action: Effective July 1, 2025, FCOM implemented new processes and procedures to enhance FFATA reporting controls and ensure the accuracy and timeliness of the subaward data reported in the SAM.GOV. Anticipated Completion Date: 7/1/2025 Responsible Contact...
Finding Number: 2025-033 Planned Corrective Action: Effective July 1, 2025, FCOM implemented new processes and procedures to enhance FFATA reporting controls and ensure the accuracy and timeliness of the subaward data reported in the SAM.GOV. Anticipated Completion Date: 7/1/2025 Responsible Contact Person: Tisha Womack
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