Corrective Action Plans

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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: 2025-002 Planned Corrective Action: During testing of payroll transactions, the auditor identified that one or more payroll submissions lacked documented email approval from the Director of Finance prior to submission, as required by internal control policy. Although approval was ver...
Finding Number: 2025-002 Planned Corrective Action: During testing of payroll transactions, the auditor identified that one or more payroll submissions lacked documented email approval from the Director of Finance prior to submission, as required by internal control policy. Although approval was verbally or electronically obtained, documentation was not consistently retained in accordance with policy. The organization has strengthened documentation procedures moving forward. The lack of documented approval occurred due to:  Inconsistent retention of email approvals, and/or  Staff misunderstanding of documentation requirements, and/or o Accounting team faced significant turnover with personnel completing payroll tasks  Payroll deadlines not being met, consistently, by organization’s management team The organization has implemented the following corrective actions:  Re-trained payroll and finance staff on the requirement that all payroll submissions must receive documented email approval from the Director of Finance prior to processing.  Implemented a standardized payroll submission checklist requiring confirmation of email approval before processing.  Established a centralized electronic folder where all payroll approval emails must be saved and retained.  Required organization’s management team to adhere to payroll deadlines set by Accounting Team or disciplinary actions will be taken.  The Senior Accountant will perform quarterly internal spot checks of payroll files to verify documentation is complete.  The Director of Finance will review and sign off monthly on a payroll approval log confirming compliance.  Failure to obtain documented approval will result in payroll submission delay until documentation is secured. Anticipated Completion Date: 08/31/2026 Responsible Contact Person: Dr. Brittany Lee
Finding Number: 2025-003 Condition: The College did not perform an accurate calculation to determine the amount of funds to return of Title IV funds for 2 students. Planned Corrective Action: Accuracy in performing the required Return to Title IV Funds function is of significant importance to Lake M...
Finding Number: 2025-003 Condition: The College did not perform an accurate calculation to determine the amount of funds to return of Title IV funds for 2 students. Planned Corrective Action: Accuracy in performing the required Return to Title IV Funds function is of significant importance to Lake Michigan College. Currently, a second individual performs an independent review of a sample of calculations. Although we find these two scenarios to be isolated in nature, we will increase our quality control sample review. We are also investigating how we might automate more of the process in order to help reduce any manual error. The two situations noted have been corrected. Contact person responsible for corrective action: Ben Burton, Director of Financial Aid Anticipated Completion Date: 03/15/2026
Finding Number: 2025-002 Condition: If an institution enters into a Tier One arrangement with a third party servicer, as defined in CFR 668.164(e)(1), the institution must provide to the secretary an up-to-date URL for the contract and contract data, as described in paragraph (e)(2)(vii) of this sec...
Finding Number: 2025-002 Condition: If an institution enters into a Tier One arrangement with a third party servicer, as defined in CFR 668.164(e)(1), the institution must provide to the secretary an up-to-date URL for the contract and contract data, as described in paragraph (e)(2)(vii) of this section for publication in a centralized database accessible to the public. Planned Corrective Action: The URL associated with Lake Michigan’s required disclosure has now been provided to the secretary via the associated Department of Education’s instructions. Contact person responsible for corrective action: Ben Burton, Director of Financial Aid Anticipated Completion Date: 03/19/2026
2025-003 – Pell Under-Award Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend that a review is implemented to ensure calculations of Pell awards are performed based on the accurate cost of attendance, SAI and enrollment status of the student. Explanation of disa...
2025-003 – Pell Under-Award Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend that a review is implemented to ensure calculations of Pell awards are performed based on the accurate cost of attendance, SAI and enrollment status of the student. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the audit review, it was determined that student (ID: 0364337) was under-awarded a Federal Pell Grant due to a manual calculation error. Based on remaining Lifetime Eligibility Used (LEU), the student was eligible for $1,085 but was awarded $627.97. To address this finding, the institution has strengthened internal controls by eliminating manual calculations as a primary method for determining Pell eligibility, implementing a mandatory secondary review prior to disbursement, and requiring verification of LEU through the COD system. In addition, ongoing monthly quality assurance reviews have been established, and staff training has been completed to reinforce compliance with Pell Grant calculation requirements, including Cost of Attendance (COA), Student Aid Index (SAI), and enrollment status. Name(s) of the contact person(s) responsible for corrective action: Kathy Prieto -Executive Director Student Financial Services Planned completion date for corrective action: March 2026.
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 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: 2025-043 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: 2025-024 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: 2025-021 Planned Corrective Action: As recommended by the Florida Auditor General’s office, FDOE will take the following actions to enhance payment controls to ensure that costs are attributable to the authorized period of performance and are charged to the correct Federal award: 1. ...
Finding Number: 2025-021 Planned Corrective Action: As recommended by the Florida Auditor General’s office, FDOE will take the following actions to enhance payment controls to ensure that costs are attributable to the authorized period of performance and are charged to the correct Federal award: 1. Identify the CCDF transactions falling before the October 1, 2024, performance period begin date for grant SMT25 and make the necessary corrections in FLAIR. Those corrections were completed October 31, 2025 and the associated FLAIR records were provided to the Auditor December 11, 2025 by upload to the ShareFile with email confirmation. The identified transactions were for services provided in September 2024 and those transactions were moved to discretionary grant SDI24. The period of performance for grant SDI24 began October 1, 2023, and ends September 30, 2026. These actions resolve the questioned costs the auditor noted. 2. Enhance the Division of Early Learning’s revenue and payment procedures to include verification by the Division’s assigned Revenue and Budget Supervisor that all period of performance information for active grants has been communicated in writing to the Division’s budget and accounting staff. Information will include active grant numbers, project period begin and end dates, amount of awards and obligation periods for all applicable funding streams to include CCDF, TANF, and SSBG. 3. Enhance the Division of Early Learning’s revenue and payment procedures to include periodic expenditure review to ensure no payments are made for a service period falling outside of the performance period of the funding used. 4. Enhance the Division of Early Learning’s revenue and payment procedures to include procedures and timeframes for correcting any errors discovered in the course of periodic expenditure review. 5. Enhance the Division of Early Learning’s revenue and budget procedures to include a multi-layer review and approval process to include the Division’s Budget and Revenue Supervisor and Manager as documented by a signed routing form. Anticipated Completion Date: May 31, 2026 Responsible Contact Person: James Finch
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
Finding Number: 2025-031 Planned Corrective Action: As part of continuous process improvement, OIT is in the process of implementing additional improvement measures. Anticipated Completion Date: July 1, 2026 Responsible Contact Person: Sandy Barnes
Finding Number: 2025-031 Planned Corrective Action: As part of continuous process improvement, OIT is in the process of implementing additional improvement measures. Anticipated Completion Date: July 1, 2026 Responsible Contact Person: Sandy Barnes
Finding Number: 2025-030 Planned Corrective Action: As part of continuous process improvement, the Office of Information Technology (OIT) is in the process of implementing additional improvement measures. Anticipated Completion Date: August 31, 2026 Responsible Contact Person: Mark Stich
Finding Number: 2025-030 Planned Corrective Action: As part of continuous process improvement, the Office of Information Technology (OIT) is in the process of implementing additional improvement measures. Anticipated Completion Date: August 31, 2026 Responsible Contact Person: Mark Stich
Finding Number: 2025-029 Planned Corrective Action: Security controls will be implemented at the application/system level. Anticipated Completion Date: June 30, 2028 Responsible Contact Person: Kevin Wiggins, Information Security Manager
Finding Number: 2025-029 Planned Corrective Action: Security controls will be implemented at the application/system level. Anticipated Completion Date: June 30, 2028 Responsible Contact Person: Kevin Wiggins, Information Security Manager
Finding Number: 2025-028 Planned Corrective Action: FDCF will perform periodic monitoring and issue a policy refresher to ensure child support sanctions are timely reviewed and properly imposed. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Robert Hogan, Chief of Quality Man...
Finding Number: 2025-028 Planned Corrective Action: FDCF will perform periodic monitoring and issue a policy refresher to ensure child support sanctions are timely reviewed and properly imposed. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Robert Hogan, Chief of Quality Management Terri Lynch, Director of ESS Operations
Finding Number: 2025-020 Planned Corrective Action: Bureau of Epidemiology budget staff worked with the Department’s Office of Budget & Revenue Management (OBRM) to enhance controls to ensure compliance. Moving forward, staff will ensure the following: • Prior to sending the financial reports for ap...
Finding Number: 2025-020 Planned Corrective Action: Bureau of Epidemiology budget staff worked with the Department’s Office of Budget & Revenue Management (OBRM) to enhance controls to ensure compliance. Moving forward, staff will ensure the following: • Prior to sending the financial reports for approval if any adjustments are needed, send email of the correction (TR58/TR51) for OBRM to record on their reconciliation report. • Any notes that are made in the Cooperative Agreement Management Platform that are not seen on the financial reports extracted for approval will need to be also noted on the financial reports next to the appropriate project. • Send the financial reports with our recommendations to receive approval from OBRM. • The authorized official in OBRM will then sign off next to the amounts to show that there was an agreement of numbers. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Brianna Caprioni
Finding Number: 2025-019 Planned Corrective Action: Bureau of Epidemiology staff will implement a second level review on all expenditures to ensure they occurred in the authorized period of performance and make corrections when errors are identified. Anticipated Completion Date: June 30, 2026 Respon...
Finding Number: 2025-019 Planned Corrective Action: Bureau of Epidemiology staff will implement a second level review on all expenditures to ensure they occurred in the authorized period of performance and make corrections when errors are identified. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Brianna Caprioni
Finding Number: 2025-017 Planned Corrective Action: Beginning in the 2025-26 fiscal year, the Immunization Section implemented a policy requiring field staff to complete a compliance site visit to all providers in their assigned areas at least annually, rather than the two-year requirement establish...
Finding Number: 2025-017 Planned Corrective Action: Beginning in the 2025-26 fiscal year, the Immunization Section implemented a policy requiring field staff to complete a compliance site visit to all providers in their assigned areas at least annually, rather than the two-year requirement established by the Centers for Disease Control and Prevention (CDC) Vaccines for Children program. Spreadsheets were created to track assigned sites and due dates. Completion of compliance visits has also been added to field staff performance standards. The new policy also updated the process for conducting and documenting Orientation Site Visits (OSR). The program requires staff to conduct OSRs in person. Documentation is uploaded in CDC’s Provider Education, Assessment, and Reporting online system, and back-up documentation is uploaded to a FDOH shared drive and reviewed by the field staff’s supervisor. The supervisor maintains a spreadsheet with information on site visits and OSRs and follows up with staff on any missing documentation. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Tom Bendle
Finding Number: 2025-016 Planned Corrective Action: Immunization Section staff will implement a second level review on all expenditures to ensure they occurred in the authorized period of performance and make corrections when errors are identified. Anticipated Completion Date: June 30, 2026 Responsi...
Finding Number: 2025-016 Planned Corrective Action: Immunization Section staff will implement a second level review on all expenditures to ensure they occurred in the authorized period of performance and make corrections when errors are identified. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Tom Bendle
Finding Number: 2025-014 Planned Corrective Action: Expenditures reviewed were for services or travel that occurred in June at the end of the grant budget period/state fiscal year but were paid by the Florida Department of Health (Department, FDOH) in July. During this time new Other Cost Accumulato...
Finding Number: 2025-014 Planned Corrective Action: Expenditures reviewed were for services or travel that occurred in June at the end of the grant budget period/state fiscal year but were paid by the Florida Department of Health (Department, FDOH) in July. During this time new Other Cost Accumulators (OCA) are created to match the new budget period/state fiscal year. Of the 16 expenditures provided to the Public Health Emergency Preparedness Program (PHEP) for review, 11 were for purchasing card (Pcard) charges for travel that occurred at the end of June but cleared in July. Previous year’s codes are not available when clearing Pcard charges from a previous fiscal year. The remaining expenditures were for payments that were redistributed by finance and accounting and could not be charged to current fiscal year OCAs once the new fiscal year began. Language has been added to the PHEP’s checkbook review process to specifically identify expenses that occur at the end of a budget period/fiscal year but are cleared or paid at the beginning of the next fiscal year. A correction will be submitted to move those expenses to the previous fiscal year as appropriate. Anticipated Completion Date: Completed Responsible Contact Person: Jennifer Coulter
Finding Number: 2025-006 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: 2025-006 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
Finding Number: 2025-013 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: 2025-013 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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