Corrective Action Plans

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The Health System met with grant managers and reviewed the expectations and responsibilities to ensure appropriate reviews and sign offs prior to submitting reports to the granting agency. The Health System will implement a centralized process with dedicated resources that will establish consistent ...
The Health System met with grant managers and reviewed the expectations and responsibilities to ensure appropriate reviews and sign offs prior to submitting reports to the granting agency. The Health System will implement a centralized process with dedicated resources that will establish consistent policies for grant management, including a layered review process with executive sign off on reports prior to submission.
Management response: Warren Easton is reviewing and updating the procurement section of the policy manual to explicitly include procedures for verifying the suspension and debarment status of all vendors and contractors receiving federal funds. Documentation of each vendor's verification will be mai...
Management response: Warren Easton is reviewing and updating the procurement section of the policy manual to explicitly include procedures for verifying the suspension and debarment status of all vendors and contractors receiving federal funds. Documentation of each vendor's verification will be maintained in procurement files. A printed or PDF record from SAM.gov showing the vendor's status will be retained as audit evidence.
Finding 2024-001 – Special Tests and Provisions, SEMAP reporting – ALN 14.871 – Significant Deficiency & Other Matter Corrective Action Plan: Since the audit, I have completed a SEMAP training course provided by The Nelrod Company. I will draft a binder for each indicator. I will complete the anal...
Finding 2024-001 – Special Tests and Provisions, SEMAP reporting – ALN 14.871 – Significant Deficiency & Other Matter Corrective Action Plan: Since the audit, I have completed a SEMAP training course provided by The Nelrod Company. I will draft a binder for each indicator. I will complete the analysis for each indicator and provide verification of all findings. Person Responsible: Annette Carper, Executive Director Anticipated Completion Date: I have completed the SEMAP training. The FYE 2025 SEMAP is due to be submitted by July 31, 2025. I will prepare a binder that will show collected data from August 1, 2024-July 31, 2025.
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2024 Finding 2024-001 - Non-Compliance with Accurate Student Enrollment Change Submissions to the National Student Loan Data System (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Fina...
MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN For the year ended December 31, 2024 Finding 2024-001 - Non-Compliance with Accurate Student Enrollment Change Submissions to the National Student Loan Data System (Significant Deficiency) Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Award Titles: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2023 – 6/2025 Management agrees with the finding and proposes the following corrective action plan: Corrective Action Plan: Due to non-compliance with timely and accurate student enrollment change submissions to the National Student Loan Data System (NSLDS), Brigham Young University – Hawaii (BYUH) Management proposes the following corrective action plan to mitigate reporting errors. The Registrar’s Office, in coordination with BYUH’s Enterprise Information Systems team, will review and enhance the processes used to extract student data from PeopleSoft and transmit it to the National Student Clearinghouse (NSC) and NSLDS. This includes: -Reviewing all relevant PeopleSoft updates and ensuring that corresponding changes are reflected in the data transmitted to NSLDS. -Testing and validating the reporting processes within PeopleSoft to confirm data accuracy and completeness. -Verifying that the correct data is being transmitted to NSLDS. -Testing the student data within NSLDS to ensure its integrity. -Documenting the entire process for future reference and ongoing quality assurance. In addition, the Registrar’s office has already added additional resources to run all reporting processes. The Registrar’s office has also reached out to Ensign College to learn about their reporting process. The University is considering contacting the PeopleSoft reporting specialist that Ensign used, although that decision will be made at a later date, and if necessary. These actions will enable the Registrar’s Office to more effectively review credit load determinations and accurately establish program begin dates for students. Daryl Whitford, Registrar, will remain responsible for enrollment reporting at BYUH. She will oversee the implementation of the revised process, provide training to all relevant staff members, and lead the development and implementation of a control mechanism to ensurefuture compliance with NSLDS reporting requirements within PeopleSoft. Timing: Daryl Whitford, Registrar, will be responsible for overseeing that all items noted in the corrective action plan will be implemented by September 1, 2025. Signed and Acknowledged Daryl Whitford, BYUH Registrar
Finding 560845 (2024-001)
Significant Deficiency 2024
Finding 2024-001 Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: In conjunction with the Town Administrator and Accountant, the Select Board will establish a written policy based on Uniform Guidance regarding cash management,...
Finding 2024-001 Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: In conjunction with the Town Administrator and Accountant, the Select Board will establish a written policy based on Uniform Guidance regarding cash management, determination of allowable costs, employee travel, procurement and subrecipient monitoring pertaining to federal awards. Anticipated Completion Date: December 31, 2025 Contact: Holly Young, Interim Town Administrator
2024-002 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should evaluate their procedures and review policies surrounding reporting enrollment effective dates and program enrollment effective dates NSLDS. Explanation of disagreement with audit finding...
2024-002 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should evaluate their procedures and review policies surrounding reporting enrollment effective dates and program enrollment effective dates NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Through the review of program reporting and campus reporting, the college will identify the cause for the data error. The college will explore the impact of branch campuses and the potential to shift to a single college reporting model. The following specific steps will be completed. 1. Identify and Analyze the Issues 2. Root Cause Analysis 3. Corrective Measures 4. Automation: Implement automated checks and balances to ensure data integrity before files are processed and sent. Name(s) of the contact person(s) responsible for corrective action: Patricia Munsch, Ph.D. Vice President for Student Affairs Nancy Brewer, College Director for Financial Aid Cheryl Eldredge, College Associate Dean for Registrar and Master Schedule Planned completion date for corrective action plan: December 31, 2026
2024-001 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. The College shoul...
2024-001 Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. The College should evaluate their procedures and review policies surrounding reporting status changes to NSLDS to ensure the enrollment effective date reported to NSLDS aligns with the College’s last date of attendance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Through the work of a college-wide task force the following actions will be taken in response to the finding. The task force will include representatives from Information Technology, Institutional Research, Financial Aid, Registrar, along with Ellucian consultants. To summarize the steps and details of implementation to the specific areas are as follows: 1. Review Reporting Controls and Procedures 2. Address Error Code 22 3. Review Procedures Surrounding Reporting Status Changes 4. Assure Accuracy in Reporting Enrollment Effective Date Name(s) of the contact person(s) responsible for corrective action: Patricia Munsch, Ph.D. Vice President for Student Affairs Nancy Brewer, College Director for Financial Aid Planned completion date for corrective action plan: December 31, 2026
2024-003 Student Financial Aid Cluster – Assistance Listing 84.063, 84.268, 84.007, and 84.033 Recommendation: We recommend reviewing and implementing GLBA guidelines in order to explain the College’s information-sharing practices to their customers and to safeguard sensitive data, including student...
2024-003 Student Financial Aid Cluster – Assistance Listing 84.063, 84.268, 84.007, and 84.033 Recommendation: We recommend reviewing and implementing GLBA guidelines in order to explain the College’s information-sharing practices to their customers and to safeguard sensitive data, including student financial information. We also recommend designating a qualified individual responsible for implementing and monitoring the institution’s information security program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College is working toward documenting its policy and procedures with the proper oversight and its continual monitoring of all GLBA guidelines and the sensitive student data therein. While the College has been in the practice of safeguarding all its sensitive student data and adhering to all the GLBA guidelines. It has not been properly documented. The qualified designated individual responsible for the implementation and continued monitoring is Jason Fried, College Director of Service Delivery and IT Compliance. Name(s) of the contact person(s) responsible for corrective action: Sara E. Gorton, CPA, Vice President for Business and Financial Affairs Holmer A. Avellan, CPA, CFE, Controller Jaime Hahn, Senior Auditor Stephen Clark, College Administrative Director of Infrastructure Services Jason Fried, College Director of Service Delivery and IT Compliance Planned completion date for corrective action plan: August 31, 2025 If the Department of Education has questions regarding this plan, please call: Sara Gorton, CPA, VP of Finance and Business Affairs 631-451-4223
Views of Responsible Officials: The Grants manager and Grants Compliance manager positions had turnover in 2024. The search for their replacements continues. With various temporary staff filling the roles in 2024, delays occurred in meeting reporting deadlines. Management has reviewed all agreements...
Views of Responsible Officials: The Grants manager and Grants Compliance manager positions had turnover in 2024. The search for their replacements continues. With various temporary staff filling the roles in 2024, delays occurred in meeting reporting deadlines. Management has reviewed all agreements to ensure its tracking tools reflect all relevant due dates for financial and narrative reports, as required by the agreements. These tracking tools will be monitored monthly to ensure timely submissions of reports by the established due dates.
Finding 560587 (2024-001)
Significant Deficiency 2024
Reference Number: 2024-001 Name of Contact Person: Claudia Martinez, Finance Director Corrective Action: The City agrees with the finding. The City acknowledges the importance of timely submission of the Single Audit report in accordance with Uniform Guidance 2 CFR 200.512(a) and will take correct...
Reference Number: 2024-001 Name of Contact Person: Claudia Martinez, Finance Director Corrective Action: The City agrees with the finding. The City acknowledges the importance of timely submission of the Single Audit report in accordance with Uniform Guidance 2 CFR 200.512(a) and will take corrective action to remediate this issue. The City is committed to restoring compliance with federal reporting deadlines and will continue to evaluate and implement process improvements to ensure timely completion and submission of future Single Audit reports. Proposed Completion Date: The corrective actions outlined above will be fully implemented by June 30, 2025.
Finding 560570 (2024-001)
Significant Deficiency 2024
Name of Contact Person: Elizabeth Shavelson, Assistant Chief Financial Officer Corrective Action: The City has established a timeline and identified milestones for its audit and financial reporting process for the Fiscal Year Ended June 30, 2025. The City will initiate the process much earlier to a...
Name of Contact Person: Elizabeth Shavelson, Assistant Chief Financial Officer Corrective Action: The City has established a timeline and identified milestones for its audit and financial reporting process for the Fiscal Year Ended June 30, 2025. The City will initiate the process much earlier to allow more time for completion and will continue to track and monitor is progress against its established milestones throughout the process. Along with filling vacant staff positions, the City has engaged a consultant to assist the Finance Department in developing and enhancing documentation specific to financial reporting procedures. The City has also been working with its financial software support team to streamline certain ERP system configurations in order to improve the City’s financial reporting process. Proposed Completion Date: 12/31/2025
Management Response: Management concurs with the finding and will reconcile the College’s disbursement records with the federal COD system and correct all errors on a monthly basis.
Management Response: Management concurs with the finding and will reconcile the College’s disbursement records with the federal COD system and correct all errors on a monthly basis.
View Audit 356480 Questioned Costs: $1
Management Response: Going forward, all students who withdraw from the College will be forwarded to the financial aid team to review whether a student is still eligible for the full funding of the specific semester in question or whether funding needs to be returned based on the withdrawal date. If ...
Management Response: Going forward, all students who withdraw from the College will be forwarded to the financial aid team to review whether a student is still eligible for the full funding of the specific semester in question or whether funding needs to be returned based on the withdrawal date. If it is deemed that funds need to be returned, the Bursar will provide the financial aid team with a copy of the student charges for that period and the Registrar will provide proof of the withdrawal date and the financial aid team will determine the amount of funding that needs to be returned. Financial aid will then complete the return through the student's account and notify the Controller and VP of Finance and Administration to process the return to G5.
View Audit 356480 Questioned Costs: $1
Management Response: The College concurs with the finding and is in the process of implementing a policy when satisfactory academic progress is run, students will be notified via mail or email of their academic standing. Students who are suspended will have an opportunity to appeal their suspension....
Management Response: The College concurs with the finding and is in the process of implementing a policy when satisfactory academic progress is run, students will be notified via mail or email of their academic standing. Students who are suspended will have an opportunity to appeal their suspension. If the appeal of suspension is approved, students will meet with their academic advisor to be placed on an academic plan. The academic plan must be signed by both the student and advisor. The academic plan must be submitted to the Office of Financial Aid via the teams. A financial aid hold will be placed on the student's account until the signed academic plan is received. Once received, the Office of Financial Aid will remove the hold so the student can be awarded.
Finding 2024-005 Cash Management Federal Agency Name: U.S. Department of Health and Human Services Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services Federal Financial Assistance Listing Number: 93.829 Finding Summary: During audit testing of reimbursement...
Finding 2024-005 Cash Management Federal Agency Name: U.S. Department of Health and Human Services Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services Federal Financial Assistance Listing Number: 93.829 Finding Summary: During audit testing of reimbursement requests, there was no documentation available for the review and approval procedures performed. Responsible Individuals: Joshua Duame, Fractional CFO Corrective Action Plan: Management agrees with the finding. There was turnover in staff and the prior CFO did not keep a record of his review over cash management. In the future, management will ensure that documentation of the approval process for reimbursement is kept. Anticipated Completion Date: 5/1/2025
Housing Opportunities for Persons with AIDS – Assistance Listing No. 14.241 Recommendation: We recommend the Organization design controls to ensure the payroll data is reviewed prior to being paid out and the support is reviewed in detail when submitting to the grantor for reimbursement. Explanation...
Housing Opportunities for Persons with AIDS – Assistance Listing No. 14.241 Recommendation: We recommend the Organization design controls to ensure the payroll data is reviewed prior to being paid out and the support is reviewed in detail when submitting to the grantor for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Aids Taskforce of Greater Cleveland, Inc. will continue to review payroll as internal controls state and ensure accurate reporting. Control with payroll should be coordinated with payroll department ensuring duplicate payroll is not being processed and approved. Name(s) of the contact person(s) responsible for corrective action: Simpson Huggins Planned completion date for corrective action plan: December 31, 2025 If the Oversight Agency has questions regarding this plan, please call Simpson Huggins 216-621-0766
View Audit 356447 Questioned Costs: $1
Finding 560528 (2024-002)
Significant Deficiency 2024
Condition: Obligations and expenditures were overstated by $93,955 on the March 31, 2024 Project and Expenditure report. Corrective Action Planned: Town Administrator will work with CSS Capital Strategic Solutions LLC to potentially amend the filing with the Treasury. Anticipated Completion Date...
Condition: Obligations and expenditures were overstated by $93,955 on the March 31, 2024 Project and Expenditure report. Corrective Action Planned: Town Administrator will work with CSS Capital Strategic Solutions LLC to potentially amend the filing with the Treasury. Anticipated Completion Date: End of 2025 Contact: Town Administrator Nelson Mui, nmui@townsendma.gov, 978-597-1700 x1703
Finding 560526 (2024-001)
Significant Deficiency 2024
Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: Town Administrator with the Selectboard will explore examples of Federal Award Policies with assistance of Town Counsel to prepare a draft for consideration. Anticipated Completion...
Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: Town Administrator with the Selectboard will explore examples of Federal Award Policies with assistance of Town Counsel to prepare a draft for consideration. Anticipated Completion Date: End of 2025 Contact: Town Administrator Nelson Mui, nmui@townsendma.gov, 978-597-1700 x1703
Finding 560522 (2024-003)
Significant Deficiency 2024
Aclamo
PA
Reporting – reports submitted to the county for the ARPA contract were not retained, effective internal controls were not in place to ensure proper document retention. ACLAMO acknowledges and agrees with Finding 2024-003 regarding the lack of effective internal controls to ensure the retention of re...
Reporting – reports submitted to the county for the ARPA contract were not retained, effective internal controls were not in place to ensure proper document retention. ACLAMO acknowledges and agrees with Finding 2024-003 regarding the lack of effective internal controls to ensure the retention of reports submitted to the County under the ARPA contract. To address this issue, the Interim Executive Director, in coordination with the Financial Team, has taken the following corrective actions: Quarterly Report Oversight: The Interim Executive Director will assume responsibility for submitting all required quarterly reports related to ARPA funding. This ensures a single point of accountability for timely and accurate reporting. Document Retention and Audit Readiness: Immediately following each report submission, ACLAMO will request confirmation of receipt and a copy of the submitted report from the County. These documents will be promptly uploaded and stored in ACLAMO’s Financial Team SharePoint Site to ensure secure access and proper audit documentation. Internal Control Enhancements: ACLAMO will also implement a formal tracking system (such as a report log) to document submission dates, confirmation receipts, and responsible staff members. This log will be reviewed quarterly by the Financial Team to ensure completeness and compliance. Staff Training: Relevant team members will receive training on proper document retention procedures, the importance of audit trails, and use of the SharePoint system to reinforce accountability and sustainability of this corrective action. ACLAMO is committed to improving its reporting systems and internal controls to ensure compliance with all federal and contractual requirements and to promote transparency and accountability.
Views of Responsible Officials: Timesheets are now being submitted with every payroll to the proper supervisor for review and signatures.
Views of Responsible Officials: Timesheets are now being submitted with every payroll to the proper supervisor for review and signatures.
Views of Responsible Officials: DREF is in the process of hiring a part-time CFO to review all financial reports.
Views of Responsible Officials: DREF is in the process of hiring a part-time CFO to review all financial reports.
Finding 560362 (2024-002)
Significant Deficiency 2024
Finding Number – 2024-001 Procurement Finding & 2024-002 Payroll Finding Planned Corrective Action 1. Policy Development: Draft a comprehensive procurement policy that aligns with federal standards and addresses all required elements, including conflict of interest provisions and procurement methods...
Finding Number – 2024-001 Procurement Finding & 2024-002 Payroll Finding Planned Corrective Action 1. Policy Development: Draft a comprehensive procurement policy that aligns with federal standards and addresses all required elements, including conflict of interest provisions and procurement methods. 2. Approval Process: Present the drafted policy to leadership or the governing body for review and approval. 3. Implementation: Roll out the approved procurement policy to all relevant departments and stakeholders. 4. Training: Conduct training sessions to ensure staff understand and comply with the new procurement procedures. 5. Monitoring: Establish a system to regularly review procurement activities for compliance with the policy and federal regulations. 6. Implement a system of internal controls to ensure payroll charges are supported by accurate records reflecting actual work performed. This system should include regular reconciliation of estimated payroll allocations with actual time worked and documented certifications by employees or supervisors. Anticipate Completion Date – May 31, 2025 Responsible Contact Person – Monique Langston, Grant Director
Finding 560361 (2024-001)
Significant Deficiency 2024
Finding Number – 2024-001 Procurement Finding & 2024-002 Payroll Finding Planned Corrective Action 1. Policy Development: Draft a comprehensive procurement policy that aligns with federal standards and addresses all required elements, including conflict of interest provisions and procurement methods...
Finding Number – 2024-001 Procurement Finding & 2024-002 Payroll Finding Planned Corrective Action 1. Policy Development: Draft a comprehensive procurement policy that aligns with federal standards and addresses all required elements, including conflict of interest provisions and procurement methods. 2. Approval Process: Present the drafted policy to leadership or the governing body for review and approval. 3. Implementation: Roll out the approved procurement policy to all relevant departments and stakeholders. 4. Training: Conduct training sessions to ensure staff understand and comply with the new procurement procedures. 5. Monitoring: Establish a system to regularly review procurement activities for compliance with the policy and federal regulations. 6. Implement a system of internal controls to ensure payroll charges are supported by accurate records reflecting actual work performed. This system should include regular reconciliation of estimated payroll allocations with actual time worked and documented certifications by employees or supervisors. Anticipate Completion Date – May 31, 2025 Responsible Contact Person – Monique Langston, Grant Director
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE West Valley School District No. 363 September 1, 2023 through August 31, 2024 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code o...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE West Valley School District No. 363 September 1, 2023 through August 31, 2024 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2024-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal Title I assessment system security requirements. Name, address, and telephone of District contact person: Ayesha Horton, Chief Financial Officer 2805 N Argonne Rd, Spokane, WA 99212 (509) 924-2150 Corrective action the auditee plans to take in response to the finding: The district acknowledges that a Test Security Building Plan (TSBP) was not on file for our Kindergarten Center during the 2023–24 school year. While all required testing assurances were submitted and staff received appropriate test security training, we recognize that the omission of a formal TSBP represents a lapse in documentation and controls. This oversight occurred during a period of staffing transition in the district’s assessment position, which contributed to the gap in plan submission for the Kindergarten Center. We appreciate the auditor's recommendation and have taken corrective action to address this issue. For the 2024–25 school year, we have verified that TSBPs are on file for all buildings where standardized assessments will be administered, including the Kindergarten Center. Looking ahead to the 2025–26 school year, our Kindergarten Center will no longer administer standardized assessments, as kindergarten students will transition back to their neighborhood elementary schools. This organizational change will further streamline compliance with OSPI’s assessment system security requirements. Anticipated date to complete the corrective action: 6/13/2025
April 22, 2025 Cognizant or Oversight Agency for Audit South Coastal Counties Legal Services, Inc. and Affiliate respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: AAFCPAs, Inc. 50 Washington Street ...
April 22, 2025 Cognizant or Oversight Agency for Audit South Coastal Counties Legal Services, Inc. and Affiliate respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: AAFCPAs, Inc. 50 Washington Street Westborough, MA 01581 Audit Period: January 1, 2024 - December 31, 2024 The findings from April 22,2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDING - FINANCIAL STATEMENT AUDIT FINDING SIGNIFICANT DEFICIENCY 2024-001 Seperation of Justice Center Recommendation: We recommend management examine their internal processes and policies on how activities for both entities are sperately accounted for to ensure proper seperation consistent with LSC requirements. We understand management has submitted a correction action plan and has been working with LSC and has already implemented several recommendations from the review and is expected to finalize and implement any remaining required recommendations in 2025. We further understand that LSC has not demanded a formal deadline for completion of the Program Integrity Review and the the Organization is not unreasonably delayed in its implementation of any corrective actions. Action Taken: SCCLS prepared and developed a corrective action plan with LSC and has met with LSC on a bi-weekly basis working with LSC to ensure that compliance with the corective action plan will result in adequate separation between entities under Title 45 of the Code of Federal Regulations. Mulitple aspects of the plan has been implemented, with full compliance expected in 2025. FINDING - FEDERAL AWARD PROGRAM AUDIT SIGNIFICANT DEFICIENCY LEGAL SERVICES CORPORATION 2023-001 Seperation of the Justice Center The significant deficiency relates to the Federal Funds received from Legal Services Corporation (LSC), Basic Field Grant, grant recipient #122087, under assistance listing number 09.112087. Recommendation: We recommend management examine their interal processes and policies on how activies for both entities are separately accounted for to ensure proper separation consistent with LSC requirements. We understand management has submitted a corrective action plan and has been working with LSC and has already implemented several recommendations from the review and is expected to finalize and implement any remaining required recommendations in 2025. We further understand that LSC has not demanded a formal deadline for completion of the Program Integrity Review and the the Organization is not unreasonably relayed in its implementation of any corrective actions. Action Taken: SCCLS prepared and develiped a corrective action plan with LSC and has met with LSC on a bi-weekly basis working with LSC to enure that compliance with the correction action plan with result in adequate separation between entities under Title 45 of the Code of Fedearl Regulations. Multiple aspects of the plan have been implemented, with full compliance expected in 2025. If Legal Services Corporation has questions regarding this plan, please call Christopher Oldi, Executive Director at (774) 488-5950 Sincerely yours, Christopher Oldi Executive Director
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