Corrective Action Plans

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The Cooperative returned the reimbursed funds to the replacement reserve. The management agent will implement a process to ensure that future reimbursed funds are returned to the replacement reserve as required by the regulatory agreement.
The Cooperative returned the reimbursed funds to the replacement reserve. The management agent will implement a process to ensure that future reimbursed funds are returned to the replacement reserve as required by the regulatory agreement.
Contact Person Misty Wanner, CFO Corrective Action Plan Management will obtain and retain all documentation as required by the federal agency. Completion Date The Organization will implement immediately.
Contact Person Misty Wanner, CFO Corrective Action Plan Management will obtain and retain all documentation as required by the federal agency. Completion Date The Organization will implement immediately.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add subrecipient monitoring policies and procedures to the organization’s grants compliance manual. These policies and procedures will ...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add subrecipient monitoring policies and procedures to the organization’s grants compliance manual. These policies and procedures will be in compliance with Uniform Guidance to ensure proper annual monitoring. Name(s) of the contact person(s) responsible for corrective action: Dr. Bart Klika, Chie_x001F_ Research O􀆯icer Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add suspension and debarment policies and procedures to the organization’s grants compliance manual. It will ensure vendor verification...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add suspension and debarment policies and procedures to the organization’s grants compliance manual. It will ensure vendor verification for suspension and debarment prior to entering into a transaction/contract. With annual review of suspension and debarment throughout the program lifecycle. Name(s) of the contact person(s) responsible for corrective action: Dr. Bart Klika, Chie_x001F_ Research O􀆯icer Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCAA will implement a formal year-end close communication process for vendors and subrecipients. Fiscal year-end reminders will be distributed by email,...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCAA will implement a formal year-end close communication process for vendors and subrecipients. Fiscal year-end reminders will be distributed by email, with a request that final invoices be submitted before the books are closed. PCAA will also maintain the books open for six weeks after fiscal year-end to help ensure expenditures are recorded in the proper fiscal year. Name(s) of the contact person(s) responsible for corrective action: Alina Birenyte, Controller Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested aft...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested after each meeting and before the draw request is submitted to the governmental agency. Name(s) of the contact person(s) responsible for corrective action: Alina Birenyte, Controller Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested aft...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested after each meeting and before the draw request is submitted to the governmental agency. Name(s) of the contact person(s) responsible for corrective action: Alina Birenyte, Controller Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: CFO will be approving CEO timesheets Name(s) of the contact person(s) responsible for corrective action: Mary Lubben, CFO Planned completion date for co...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: CFO will be approving CEO timesheets Name(s) of the contact person(s) responsible for corrective action: Mary Lubben, CFO Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
SIGNIFICANT DEFICIENCY Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required ...
SIGNIFICANT DEFICIENCY Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to ensure that actual coverage amount is kept at least at that level. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fidelity Bond coverage was increased prior to fiscal yearend on 05/29/2026 following an internal review that showed that soaring revenues had outpaced the previously enacted increased coverage. The policy has been updated to review the monthly revenue to be sure there is sufficient minimum Fidelity Bond coverage prospectively. Name(s) of the contact person(s) responsible for corrective action: Edward Forfa, Executive Director, Berkshire Retirement Home, Inc. DBA Berkshire Place, 290 South Street, Pittsfield, MA 01201 413-445-4056 #160; eforfa@berskhireplace.com Planned completion date for corrective action plan: 05/29/2026
Finding 2026-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2027 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non-e...
Finding 2026-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2027 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non-enrollment reporting to NSLDS through NSC. The Office of the Registrar has adjusted the Degree Verify submission from every 45 days to every 30 days to NSC to ensure graduation dates are reported in a more timely fashion for NSLDS within the required 60 days for financial aid. Starting Summer 2026, the Office of the Registrar has begun inactivating academic programs for students who have not had registration activity within the last two to three academic years to ensure that they are not reported as enrolled to NSC/NSLDS. NSC Enrollment Reporting will continue to be submitted every 30 days and the Office of the Registrar has worked to review the reporting criteria using terms and not semesters to better report active enrollment in current courses. The Ellucian Graduation Application form and process is in the final stages of testing which will eliminate completely the need to add a pseudo course with a future date after the student’s current program has been inactivated or graduated. The Office of the Registrar will be more proactive with the colleges for identifying students who have not graduated within the six year (undergraduate), four year (graduate) and certificate time frames by working with the appropriate dean’s offices. This should eliminate those students who have completed their coursework; close to completing their coursework but were never reviewed by their advisor/program for graduation. Since Regis uses the end date of the last course completed, the Office of the Registrar will work with advising units to review the lists to increase a better reporting of degree completion.
Corrective action planned: Management concurs with the finding and recognizes the importance of consistently applying the correct sliding fee discount schedule in effect at the time services are rendered. To address this finding, the organization has implemented enhanced monitoring and training cont...
Corrective action planned: Management concurs with the finding and recognizes the importance of consistently applying the correct sliding fee discount schedule in effect at the time services are rendered. To address this finding, the organization has implemented enhanced monitoring and training controls over the application of the sliding fee discount schedules. The Director of Patient Services (or designee) will perform monthly audits of 25 randomly selected patients accounts that received a sliding fee discount to verify that the correct discount schedule was applied and that the patient responsibility was calculated accurately. In addition, for any future changes to the sliding fee discount schedule, management will implement a transition review process that includes: • Verification that the updated fee schedule is accurately loaded into the billing system prior to the effective date and old fee schedules are inactivated. • Additional training for billing staff before implementation of any revised sliding fee schedule. • Continued monthly audits of sliding fee discounted patient accounts. • Quarterly reporting of audit results to Chief Financial Officer, to identify recurring issues and ensure corrective actions taken are effective. Anticipated completion date: July 31, 2026
The CFO corrected the Federal Draw schedule to identify the payroll used each pay period for the draw request. The schedule shows the replacement of termed staff and a countdown of available grant dollars per staff. This report balances the Federal Draw schedule every pay period.
The CFO corrected the Federal Draw schedule to identify the payroll used each pay period for the draw request. The schedule shows the replacement of termed staff and a countdown of available grant dollars per staff. This report balances the Federal Draw schedule every pay period.
Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a p...
Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and monthly review and testing of compliance with Center sliding fee discount policy will be done.
Federal Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No. 10.557 Recommendation: Our auditors recommended the Organization update its grant allocation process and controls to ensure accurate documentation of expenditures allocated to the gr...
Federal Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No. 10.557 Recommendation: Our auditors recommended the Organization update its grant allocation process and controls to ensure accurate documentation of expenditures allocated to the grant are retained and accurate fringe benefit costs incurred during the month are used to calculate the allocations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has updated the grant allocation process and controls to ensure accurate documentation of expenditures allocated to the grant are retained and accurate fringe benefit costs incurred during the month are used to calculate the allocations. As part of this update management has reassigned responsibilities for various grants to ensure the process is followed.
Finding 2026-002 CAPBM acknowledges the finding regarding inaccuracies identified in several tenant annual recertifications that required corrected HUD-50059-A forms to accurately reflect the Total Tenant Payment (TTP) and HUD subsidy amounts. The errors were the result of calculation and data entry...
Finding 2026-002 CAPBM acknowledges the finding regarding inaccuracies identified in several tenant annual recertifications that required corrected HUD-50059-A forms to accurately reflect the Total Tenant Payment (TTP) and HUD subsidy amounts. The errors were the result of calculation and data entry mistakes during the annual recertification process with past management. Current management is currently reviewing the affected tenant files and will complete any necessary corrections to ensure tenant rent and subsidy calculations are accurate and compliant with HUD requirements. To prevent similar errors in the future, CAPBM has implemented an additional review procedure for all annual recertifications. Once the Compliance Manager completes the annual recertification and prepares the HUD-50059, the Director of Affordable Housing will conduct a secondary review of the certification, including income calculations, asset determinations, applicable deductions, Total Tenant Payment (TTP), and subsidy calculations, prior to final approval and submission. Additionally, staff will continue to receive training on HUD occupancy requirements and annual recertification procedures to ensure compliance with HUD regulations. Management believes these corrective actions will strengthen internal controls and reduce the likelihood of future calculation errors. CAPBM is committed to maintaining accurate tenant certifications and ensuring ongoing compliance with HUD requirements. Completion Date: 12/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Finding 2026-004 Plan: Please see below the new process regarding hiring additional staff and turnover at Community Action Partnership Belknap-Merrimack Counties Inc. Due to lack of management, it is understood the importance of having staff training on a regular basis to ensure management and compl...
Finding 2026-004 Plan: Please see below the new process regarding hiring additional staff and turnover at Community Action Partnership Belknap-Merrimack Counties Inc. Due to lack of management, it is understood the importance of having staff training on a regular basis to ensure management and compliance duties can be performed adequately. Community Action Program Belknap-Merrimack Counties Inc. plans to improve the standards of employee training and will be hosting quarterly trainings on employee responsibilities, performance, and areas for improvement. This includes HUD trainings and keeping up to date on any new HUD policies and procedures. We understand the importance of a well-trained staff. We are committed to our performance and adhering to HUD standards while implementing policies to follow for continuous improvement. Please see below the new process regarding filling vacancies and completing management duties in a timely manner: 1. Immediate Focus on Vacancies: We are prioritizing the filling of vacant units by having two staff members complete move ins at the same time. 2. Streamlined Recertification Process: We have updated our process to ensure all tenants are recertified in a timely manner. There has been a new system in place to monitor deadlines and improve efficiency. 3. Staffing and Training: We are actively recruiting and training additional staff to ensure these tasks are handled promptly, preventing future delays. These steps will address the backlog of management duties and ensure that all tasks, such as filling vacancies, submitting budgets, and completing tenant recertifications, are handled in a timely and efficient manner. Completion Date: 11/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Finding 2026-001 Plan: Please see below the new process ensuring replacement reserve requests are being made in a timely manner: 1) Quarterly Assessment: Quarterly review are now in place to assess reserve balances and ensure funds are used for necessary repairs. Monthly cash flow reports will align...
Finding 2026-001 Plan: Please see below the new process ensuring replacement reserve requests are being made in a timely manner: 1) Quarterly Assessment: Quarterly review are now in place to assess reserve balances and ensure funds are used for necessary repairs. Monthly cash flow reports will align reserve balances with property needs. 2) Formal Utilization Procedure: A written procedure has been established for requesting and using replacement reserve funds. This includes clear guidelines, approval workflows, and thresholds for reserve levels based on property needs. 3) Monitoring & Reporting: Periodic audits will ensure funds are spent according to HUD guidelines. 4) Staff Training & Oversight: Staff will receive training on proper reserve management, and management will increase oversight to ensure funds are used appropriately. Completion Date: 11/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Management agrees with the finding and will enhance existing reporting procedures to require documented evidence of review and approval for reports submitted to grantors. Macdonald Center dba Maybelle Center will retain documentation of supervisory review and approval as part of its grant compliance...
Management agrees with the finding and will enhance existing reporting procedures to require documented evidence of review and approval for reports submitted to grantors. Macdonald Center dba Maybelle Center will retain documentation of supervisory review and approval as part of its grant compliance files going forward.
Noncompliant Rebate Calculation Review Controls - WIC - DPHHS - The Montana Department of Public Health and Human Services implemented a documentation tracking system and updated its procedures to require a documented review before invoicing. The department also retroactively reviewed and documented...
Noncompliant Rebate Calculation Review Controls - WIC - DPHHS - The Montana Department of Public Health and Human Services implemented a documentation tracking system and updated its procedures to require a documented review before invoicing. The department also retroactively reviewed and documented all rebate calculations for fiscal year 2026. The department completed this corrective action in May 2026. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 5/15/2026
Inadequate Support for Benefit Accuracy Measurement Reviews - UI - DLI - The Montana Department of Labor and Industry began retaining copies of the on-demand report generated from the Sun System upon learning of the concern. This process continued until October 2024, when staff confirmed that the ne...
Inadequate Support for Benefit Accuracy Measurement Reviews - UI - DLI - The Montana Department of Labor and Industry began retaining copies of the on-demand report generated from the Sun System upon learning of the concern. This process continued until October 2024, when staff confirmed that the newly developed view in the Montana Unemployment System Enhancement (MUSE) system was functioning as intended. The MUSE system now includes a real-time interface that compares its data with the Sun System, providing staff with immediate information to monitor the volume of items selected for workload sampling. Responsible Party - Robin Graham, Central Services Division Administrator, Montana Department of Labor and Industry Target Implementation Date - 12/31/2026
Inaccurate Federal Reporting - UI - DLI - The Montana Department of Labor and Industry has made several revisions to the Employment and Training Administration (ETA) 2112 preparation and reconciliation process. Additional notations have been added to the existing ETA 2112 preparation workbook, along...
Inaccurate Federal Reporting - UI - DLI - The Montana Department of Labor and Industry has made several revisions to the Employment and Training Administration (ETA) 2112 preparation and reconciliation process. Additional notations have been added to the existing ETA 2112 preparation workbook, along with screenshots to assist the preparer with accuracy. Unemployment Insurance transactional tasks have been re-assigned to the appropriate accounting and budgeting staff to improve workflow. An additional separate but collaborative bank-to-SABHRS reconciliation has been incorporated into the process. Monthly Unemployment Insurance process meetings have been reinstated for all staff who perform tasks that impact the preparation and reconciliation of the ETA 2112 report. The purpose of these meetings is to discuss any issues regarding the process and to check in on the completion of the report and its components. The department will be engaging with a sister state that uses the same vendor software for its Unemployment Insurance system in an information-sharing session. The designated state has staff experienced in ETA 2112 preparation and submission, and department staff hope to confirm that the system report utilized in the process reflects accurate data. The department has also re-engaged a previously procured vendor to conduct a reporting accuracy and efficiency assessment of the Unemployment Insurance Program. Responsible Party - Robin Graham, Central Services Division Administrator, Montana Department of Labor and Industry Target Implementation Date - 12/31/2026
Inadequate Access and Privilege Controls - TANF - LIHEAP - CHIP - Medicaid - DPHHS - The Montana Department of Public Health and Human Services completed the development of its accounts matrix for the CHIMES eligibility system in October 2025 and implemented an enhanced process for conducting and do...
Inadequate Access and Privilege Controls - TANF - LIHEAP - CHIP - Medicaid - DPHHS - The Montana Department of Public Health and Human Services completed the development of its accounts matrix for the CHIMES eligibility system in October 2025 and implemented an enhanced process for conducting and documenting access reviews, including verification of user permissions. These improvements have been fully incorporated into routine operations, and the department has implemented all aspects of the audit recommendations. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 10/24/2025
Inadequate ACF-199 Reporting Controls - TANF - DPHHS - The Montana Department of Public Health and Human Services implemented additional internal controls over the ACF-199 reports in December 2024 and completed this corrective action. This implementation was in response to the prior audit, and the c...
Inadequate ACF-199 Reporting Controls - TANF - DPHHS - The Montana Department of Public Health and Human Services implemented additional internal controls over the ACF-199 reports in December 2024 and completed this corrective action. This implementation was in response to the prior audit, and the corrective action plan should have been included with that audit. The timing of the implementation occurred between the prior audit and the current audit period. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 12/31/2024
Inadequate 1505-029 Reporting Controls - HAF - Commerce - The Montana Department of Commerce updated the Homeowners Assistance Fund reporting procedure to strengthen internal controls by requiring supervisory verification of all quarterly and annual reports. These updates ensure all reports are comp...
Inadequate 1505-029 Reporting Controls - HAF - Commerce - The Montana Department of Commerce updated the Homeowners Assistance Fund reporting procedure to strengthen internal controls by requiring supervisory verification of all quarterly and annual reports. These updates ensure all reports are complete, accurate, and fully documented prior to submission. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce Target Implementation Date - 7/1/2026
Inadequate User Access Reviews - HPC - MDT - The Montana Department of Transportation has implemented a security review for AASTHOWare to ensure compliance in 2026. Responsible Party - Kimberly Doherty, Accounting Systems Supervisor, Montana Department of Transportation Dustin Rouse, Chief Engineer,...
Inadequate User Access Reviews - HPC - MDT - The Montana Department of Transportation has implemented a security review for AASTHOWare to ensure compliance in 2026. Responsible Party - Kimberly Doherty, Accounting Systems Supervisor, Montana Department of Transportation Dustin Rouse, Chief Engineer, Montana Department of Transportation Target Implementation Date - 12/31/2026
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