Corrective Action Plans

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The Center is working with their third-party bookkeeper to ensure all federal funds are reported properly in their general ledger system in order to determine if a federal single audit is required.
The Center is working with their third-party bookkeeper to ensure all federal funds are reported properly in their general ledger system in order to determine if a federal single audit is required.
HEC will implement the following actions to correct the error and prevent recurrence: 1. Repayment of Overclaimed Funds HEC will return the full amount of overclaimed funds to the respective grant programs: - $2,986.76 to SFA AR - $5,687.74 to SFA MS 2. Payroll System Controls Enhancement HEC’s Huma...
HEC will implement the following actions to correct the error and prevent recurrence: 1. Repayment of Overclaimed Funds HEC will return the full amount of overclaimed funds to the respective grant programs: - $2,986.76 to SFA AR - $5,687.74 to SFA MS 2. Payroll System Controls Enhancement HEC’s Human Assets department will coordinate with its payroll processing vendor (UKG) to: - Review payroll configuration settings related to bonus payments. - Implement controls to ensure bonus compensation is excluded from grant-related labor distributions. 3. Monitoring and Oversight Reinforcement The VP of Government Grant Compliance will reinforce internal review procedures by: - Providing targeted guidance to the Investor Relations Grant Compliance and Fiscal teams on identifying anomalies in Wage and Hour Reports, including unusual or inflated hourly rates
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete ...
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete all tasks before abandoning their position. Before HVC takes on additional grants and duties, the administration (TA and TA Assistant) will learn the processes and portals for the current grants and recurring ones. Create how to guides to include with the new grant binders, for reporting and portal use. Have calendars for each grant. Utilize one big calendar on the wall that includes all the grant reporting periods and the annual requirements for sam.gov (log in requirement). Continue trying to fill positions and delegate workload. Proposed Completion Date: September 30, 2026.
Finding Number: 2025-004 Condition: During the audit it was identified the Road Commission did not have formal written federal policies and procedures that document the processes and controls used to administer federal awards, including procedures for compliance \with applicable federal program requ...
Finding Number: 2025-004 Condition: During the audit it was identified the Road Commission did not have formal written federal policies and procedures that document the processes and controls used to administer federal awards, including procedures for compliance \with applicable federal program requirements under Uniform Guidance (2 CFR, Part 200.303) Planned Corrective Action: Road Commission is in the process of developing and implementing a written federal policies and procedure addressing the administration of federal awards to ensure compliance with Uniform Guidance (2 CFR, Part 200). The policy will address the following key compliance areas: allowable costs, cash management, procurement, and conflict of interest. The policy shall be reviewed and modified to included all the necessary items outlined in the Uniform Guidance. Contact Person responsible for corrective action: Destain Gingell, Managing Director / CHE, Kathleen Cunningham, Finance Director Anticipated Completion Date: July 30, 2026
Condition: The Organization allocates personnel costs to federal programs based on wage forms that reflect estimated time expected to be worked across programs. Supervisors perform biweekly reviews of employee time charged within the Paylocity system and compare allocations to supporting information...
Condition: The Organization allocates personnel costs to federal programs based on wage forms that reflect estimated time expected to be worked across programs. Supervisors perform biweekly reviews of employee time charged within the Paylocity system and compare allocations to supporting information such as program schedules and caseloads. However, we noted that: - There is no formal documentation retained evidencing the supervisor's review of supporting records (e.g., caseloads, schedules) to substantiate that recorded time aligns with actual work performed; and - The only evidence of review is system approval within Paylocity, which indicates the timecard was approved but does not demonstrate the nature, extent, or basis of the review performed. Planned Corrective Action: Family Guidance Centers will require direct supervisors to document their review of supporting records (e.g., caseloads, schedules) of direct reports to substantiate that recorded time aligns with actual work performed as a part of their bi-weekly timesheet reviews. Family Guidance Centers will retain this documentation in accordance with its document retention policy. Contact person responsible for corrective action: Jim Hagestad, CFO Anticipated Completion Date: July 1, 2026
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communi...
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communications Manager completes the annual report before the reporting period deadline. • The Executive Director will review and approve the annual report before the deadline and communicate approval of the annual report to both the Contract Specialist and Communications Manager. • The Contract Specialist will send the annual report to the BIA by the deadline and retain approval forms or records. Anticipated completion date: June 2026.
Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate ...
Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate documentation to verify primary residence status as part of the CDBG/HOME loan reconciliation workbook process.  Implementing periodic monitoring procedures for loan recipients.  Maintaining documentation in loan files to support compliance throughout the affordability period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with the finding and has implemented loan file monitoring procedures to verify occupancy compliance. Name of the contact person responsible for corrective action: Melanie Marquez Planned completion date for corrective action plan: 6/30/2026
2025 – 001 Housing Choice Voucher Program – Assistance listing No. 14.871 Recommendation: We recommend the Authority review their process and internal controls for HQS annual inspections to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit ...
2025 – 001 Housing Choice Voucher Program – Assistance listing No. 14.871 Recommendation: We recommend the Authority review their process and internal controls for HQS annual inspections to ensure compliance with HUD requirements and their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Institute developed internal controls and increase vigilance of scheduled dates for inspections in accordance with regulations. Name(s) of the contact person(s) responsible for corrective action: Joyce Skelton, Section 8 Program Manager. Planned completion date for corrective action plan: June 23, 2026
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and...
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and managing files. All forms are now saved in tenant files, and not on individual laptops as they were in the past. The supervisor has also implemented schedules and tracking systems for monthly voucher submissions, annual recertifications, quarterly income checks and other processes in the occupancy workflow. In addition, the supervisor and the lead staff for housing compliance perform regular checks on tenant application paperwork and random checks on tenant files to ensure accuracy and completeness and correct any mistakes. Ongoing staff training, support and mentoring continues.
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Ivy Melen...
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Ivy Melendez, Executive Director, will be responsible to implement this corrective action by September 30, 2026.
Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers Program and will implement internal control procedures related to reasonable rent that will ensure compliance with federal regulations. Starting i...
Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers Program and will implement internal control procedures related to reasonable rent that will ensure compliance with federal regulations. Starting in August 2025, the Authority hired a third party vendor to complete rent reasonableness determinations for all Housing Choice Voucher units. Ivy Melendez, Executive Director, will be responsible to implement this corrective action by September 30, 2026.
Corrective Action Plan (CAP): The College has reviewed the Federal Pell Grant calculation identified in this finding and confirmed that the student's award was calculated incorrectly, resulting in an under-award, due to staff error in applying the enrollment intensity calculation under the rules in ...
Corrective Action Plan (CAP): The College has reviewed the Federal Pell Grant calculation identified in this finding and confirmed that the student's award was calculated incorrectly, resulting in an under-award, due to staff error in applying the enrollment intensity calculation under the rules in effect for the 2024-25 award year. The College has recalculated the student's award using the correct enrollment intensity methodology, and the additional Pell Grant funds owed to the student (616.00) have been disbursed. Financial Aid staff are committed to maintaining current knowledge of federal regulatory changes affecting Title IV award calculations. To support this, staff will continue to participate in NASFAA training and U.S. Department of Education webinars addressing Pell Grant calculation methodology and other regulatory updates on an ongoing basis, including specific training addressing changes to enrollment intensity calculations.
Corrective Action Plan (CAP): The College has reviewed the student identified in this finding and confirmed that the student had been placed on financial aid suspension during a previous term due to exceeding the 150% maximum timeframe for program completion, but the suspension status was not reflec...
Corrective Action Plan (CAP): The College has reviewed the student identified in this finding and confirmed that the student had been placed on financial aid suspension during a previous term due to exceeding the 150% maximum timeframe for program completion, but the suspension status was not reflected when the student's enrollment was subsequently evaluated, resulting in the student receiving Title IV aid for which they were not eligible during the period under audit. The College has identified that this occurred in connection with how the student's enrollment was recorded across programs within Anthology, the College's student information system, and is continuing to investigate the precise cause of the system behavior that allowed the student's Satisfacto1y Academic Progress (SAP)/150% status to not carry forward or recalculate appropriately. The aid improperly disbursed to this student has been identified, and repayment has been completed.
Corrective Action Plan (CAP): The College operates under a just- in-time (JIT) cash management model for Title IV funds, in which the disbursement date reported to COD and the date funds are credited to the student's ledger are intended to occur on the same day. Under this model, the CMN draws down ...
Corrective Action Plan (CAP): The College operates under a just- in-time (JIT) cash management model for Title IV funds, in which the disbursement date reported to COD and the date funds are credited to the student's ledger are intended to occur on the same day. Under this model, the CMN draws down Pell grant funds in conjunction with disbursing those funds to the student, rather than disbursing from institutional funds in advance of drawdown. This approach is designed to ensure the College does not hold excess cash on hand, consistent with cash management requirements under 34 CFR 668.164. The College has reviewed the six disbursements identified in this finding and confirmed that, in each instance, the COD submission was processed on schedule, but the corresponding batch process that credits funds to the student ledger ran four days later than intended, resulting in a misalignment between the reported disbursement date and the actual date the student was credited. The College has reviewed the timing and sequencing of COD submissions and ledger transactions with the Bursar's office and the Financial Aid office to ensure both are scheduled and performed on the same day. The existing weekly reconciliation process between Financial Aid and the Bursar's office will be expanded to include a verification that the disbursement date on the ledger matches the COD disbursement date. The College notes that this finding reflects a single disbursement- timing discrepancy across the sample, a reduction in both scope and recurrence compared to findings identified in prior audit periods, and reflects continued improvement in the College's cash management and COD reporting controls.
Corrective Action Plan (CAP): The College has identified that the dates of Return of Title IV Calculations and amounts (in one case) were out of compliance. The return calculations for both students identified through this audit have been completed and corrected to reflect the correct return amounts...
Corrective Action Plan (CAP): The College has identified that the dates of Return of Title IV Calculations and amounts (in one case) were out of compliance. The return calculations for both students identified through this audit have been completed and corrected to reflect the correct return amounts, if appropriate. Student 1: Student initiated an official withdrawal on October 5, 2024, and the withdrawal was processed on that date. A notification of student status was not received in the financial aid office in order to trigger an R2T4 calculation. This student's calculation was performed at the end of the fall 2024 term with the end of term processing, resulting in 89 days passing from notification to completion of R2T4. This instance resulted in an automatic trigger being built into the student information system, which sends an email to the financial aid office for each student when their status changes from active to withdrawal. Student 2: Student initiated an official withdrawal on February 13, 2025, and the withdrawal was processed on that date. The R2T4 calculation was not performed on this student until the end of spring 2025 term processing, resulting in 96 days passing from notification to completion of R2T4. Due to delayed calculations on these students, CMN will continue to work with financial aid staff and the registrar's office to streamline communication on withdrawals and students who complete the term with all F/NP grades, as indicated in CMN policy. CMN has already worked with Anthology (student information system) to provide electronic triggers to the financial aid office when a student status changes from active to drop/withdrawal. Additionally, Enrollment Management notifies all faculty by email at the beginning of the term and again prior to final grades being submitted that electronic notification must be sent by the faculty to financial aid in order to alert the financial aid office of the date of last academic engagement for students who earn an For NP grade. For the current audit period, the Director of Enrollment Management and the Financial Aid Coordinator work together to review a final grade report for all students and identify those who need R2T4 calculations based on that review. Both the director and coordinator sign the working documents to indicate that it has been reviewed by both parties. We will continue with this process and will refine as necessary, but we anticipate that this will resolve the issue of calculations not having been performed on students with all F/NP grades at the end of the term.
Corrective Action Plan (CAP): The College has identified that the dates of enrollment submissions and status changes for the two students identified in the audit were out of compliance (92 days and 66 days). The statuses of both students are correct with NSLDS. Student 1: Student earned all F grades...
Corrective Action Plan (CAP): The College has identified that the dates of enrollment submissions and status changes for the two students identified in the audit were out of compliance (92 days and 66 days). The statuses of both students are correct with NSLDS. Student 1: Student earned all F grades during the fall 2024 trimester. The student's status was changed to withdrawal in the internal student information system on January 17, 2025. This change was not communicated to NSLDS until the March 2025 enrollment report, due to issues with the February 2025 enrollment report. Student 2: Student was a non-returner in the spring 2025 trimester. The student's status was changed to withdrawal in the internal student information system on January 21, 2025. This change was not communicated to NSLDS until the March 2025 enrollment report, due to issues with the February 2025 enrollment report. The College acknowledges this repeat finding and recognizes that, although the gap was narrowed days beyond tolerance, the prior corrective action plan did not fully resolve the underlying cause of late NSLDS reporting. The previous plan relied primarily on manual identification and status-change processes within the student information system, which remained vulnerable to human error and processing delays. To address this gap, the college will implement a secondary review checkpoint that flags students with status changes in the student information system to ensure timely transmission to NSLDS. To prevent additional recurrences, the College has implemented a monthly reconciliation procedure between the Registrar's Office and the Financial Aid Office, replacing the prior plan's reliance on manual status-chang communication alone. Each month, the Registrar's Office provides a student status change report to the Financial Aid Office. The Financial Aid Office then reconciles each status change against the institution's NSLDS submission history to confirm timely and accurate reporting. This added verification step, paired with documented recordkeeping of each reconciliation cycle, directly addresses the root cause of the repeat finding by introducing a cross-office check that does not depend solely on a single manual status update being correctly carried through to NSLDS reporting.
ELIGIBILITY VERIFICATIONS – GRANTS TO STATES FOR MEDICAID PROGRAM Recommendation: It is recommended that the County increase review over casefiles and ensure verifications are sent out when necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Ac...
ELIGIBILITY VERIFICATIONS – GRANTS TO STATES FOR MEDICAID PROGRAM Recommendation: It is recommended that the County increase review over casefiles and ensure verifications are sent out when necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will remind staff to perform reviews and to ensure that verifications are sent out when necessary. Name of the contact person responsible for corrective action plan: Kayla Matter, HHS Deputy Director Planned completion date for corrective action plan: December 31, 2026
Finding 1221287 (2025-004)
Material Weakness 2025
Eligibility Determination Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesot...
Eligibility Determination Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5MAP and 2505MN5ADM Compliance Requirement Affected: Eligibility Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: It is recommended the County implement procedures to ensure the citizenship, asset, and income verification documentation in the casefiles be retained and that it matches the METS eligibility system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will review procedures and show staff proper documentation and entry into METS and staff will be reminded to perform reviews. Name of the contact person responsible for corrective action plan: Loni Swenson, Finance Director Planned completion date for corrective action plan: December 31, 2026
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount...
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount. Financial counselors have 7 business days from the return of a patient application to determine completeness and eligibity for sliding fee scale. The Chief Financial Officer, Kara Onorato, will be responsible for ensuring that this process is followed. The new policy was approved by the board of Directors in December 2025. The new process is being implemented in 2026. Internal audit began monthly audits and corrective training in February 2026 with target goal by Q3 2026.
Views of Responsible Officials and Planned Corrective Action: Management is aware of this matter and acknowledges the need to strengthen controls over the timely reconciliation and review of aged accounts payable related to federal awards. Management has implemented, or will implement, enhanced proc...
Views of Responsible Officials and Planned Corrective Action: Management is aware of this matter and acknowledges the need to strengthen controls over the timely reconciliation and review of aged accounts payable related to federal awards. Management has implemented, or will implement, enhanced procedures designed to prevent similar issues in future reporting periods, including: (1) formalizing written policies requiring monthly accounts payable reconciliations; (2) adding a review control focused specifically on items outstanding more than 90 days, including documented investigation and resolution; and (3) training accounting personnel on these procedures and related documentation requirements. Management believes these corrective actions will improve the timely identification, review, and resolution of aged accounts payable balances in future reporting periods.
Community Mental Health Services of Livingston County Single Audit Report: Corrective Action Plan Year ended September 30, 2025 Finding 2025-001- Suspension and Debarment Requirement: As required by 2 CFR 200.214, Non-Federal entities are subject to the non-procurement debarment and suspension regul...
Community Mental Health Services of Livingston County Single Audit Report: Corrective Action Plan Year ended September 30, 2025 Finding 2025-001- Suspension and Debarment Requirement: As required by 2 CFR 200.214, Non-Federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. Condition: The vendor used for this grant was not checked for suspension and debarment prior to execution of the contract. Also, the contract did not include certification that vendor was not suspended or debarred. Questioned Cost: None. Recommendation: We recommend that the CMHSP update contract language to include certification that vendor is not suspended or debarred. Corrective Action Plan LCCMHA will address the concern raised by RPC and agrees with the above recommendation. The Accounting Manager and Associate Director of Finance and Contracts will work with the Contract Manager to modify existing contract language to include certification that vendors are not suspended or debarred. This change will be implemented for fiscal year 2027 commencing 10/01/26. Responsible Party: Jim Kubus, Accounting Manager Anticipated completion date: September 30, 2026
Planned Corrective Action: When required, the District will enter into an contract to have a single audit completed by the required due date. Anticipated Completion Date: June 30, 2027 Responsible Contact Person: Cliff Angle, Superintendent
Planned Corrective Action: When required, the District will enter into an contract to have a single audit completed by the required due date. Anticipated Completion Date: June 30, 2027 Responsible Contact Person: Cliff Angle, Superintendent
Finding Reference: 2025-001 Program Name: Housing Voucher Cluster (14.871-CL) Description of Finding: HUD regulations require the Agency to inspect the unit leased to a family at least biennially to determine if the unit meets Housing Qualify Standards and must conduct quality control reinspections....
Finding Reference: 2025-001 Program Name: Housing Voucher Cluster (14.871-CL) Description of Finding: HUD regulations require the Agency to inspect the unit leased to a family at least biennially to determine if the unit meets Housing Qualify Standards and must conduct quality control reinspections. Of the 40 files tested, 5 files did not contain documentation that the biennial inspection was performed. Statement of Concurrence or Nonconcurrence: Metropolitan Development and Housing Agency agrees with Cherry Bekaert in reference to audit finding 2025-001. Corrective Action: Management acknowledges the finding and notes that the error was caused by a software issue that has since been corrected. Upon discovery, the agency immediately remedied the issue with all impacted households and conducted a comprehensive review to determine the scope of the issue. The review identified 68 impacted households out of 6,440 total Housing Choice Voucher program households, representing less than 1% of the total program population.
The City is currently implementing measures to ensure the actual hours worked is correctly coded.
The City is currently implementing measures to ensure the actual hours worked is correctly coded.
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