Corrective Action Plans

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Reporting - Community Development Block Grants - Non-Entitlement (Significant Deficiency - Other Matter) Description of Finding The Town must adhere to the reporting submission deadlines established in its agreement with the State of Connecticut. The Town is required to submit the CT DOH Form S-730 ...
Reporting - Community Development Block Grants - Non-Entitlement (Significant Deficiency - Other Matter) Description of Finding The Town must adhere to the reporting submission deadlines established in its agreement with the State of Connecticut. The Town is required to submit the CT DOH Form S-730 for each six-month period during the project. The Town did not submit the required report for the period 7/1/2024-12/31/2024 on a timely basis. Statement of Concurrence or Nonconcurrence Management agrees with the finding. Corrective Action The Town will review its reporting processes and related controls to ensure that all grantor required forms are timely filed. Name of Contact Person Richard Monico, Director of Administration/Procurement Projected Completion Date June 30, 2025
Department of Education – Direct Programs ALN # 84.268, 84.063, 84.007, 84.033 Student Financial Assistance Cluster – Special Tests and Provision – Disbursement on Behalf of Students Finding Summary: School is required to provide specific and timely notification when direct loans are being credited ...
Department of Education – Direct Programs ALN # 84.268, 84.063, 84.007, 84.033 Student Financial Assistance Cluster – Special Tests and Provision – Disbursement on Behalf of Students Finding Summary: School is required to provide specific and timely notification when direct loans are being credited to a student’s account. During the review of the direct loans disbursed to students, it was noted that notifications were not sent to students and parents as required. Responsible Individual: Director of Financial Aid Corrective Action Plan: The College is aware of the requirement and the timing of the notification. The College will create a control process to ensure proper notification of loans is sent as required. Anticipated Completion Date: Fall 2025
2025-002 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles The auditors recommend that the County implements a review control over weekly timesheets to ensure the timesheets include all program time coded on the day sheets. NCDHHS policy requires progra...
2025-002 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles The auditors recommend that the County implements a review control over weekly timesheets to ensure the timesheets include all program time coded on the day sheets. NCDHHS policy requires program salaries to be allocated and supported by payroll and attendance records for individuals. There is no disagreement with this audit finding. Annual day sheet training is now required for all staff that submit day sheets. Additionally, all new hires are required to complete day sheet training prior to submitting their first entry. A PowerBI dashboard has been created and released in June 2025 to pull data from both Workday (the County’s system of record) and our daysheet system, ISSI that provides supervisors the ability to show discrepancies between entries in real time. The County will also conduct random reviews monthly. Any discrepancies identified will be provided to staff leadership for support and correction. Additional reviews will be conducted for those staff with identified errors until released by leadership. Semi-annual reports will be provided to HHS Senior Leadership members to show trends and compliance with day sheet and timesheet entries. These reports will be created in December and June of each year. Person responsible for correction action: Leigh Anderson, HHS Business Administrator Completion date: The County has already implemented these changes.
Finding 2025-001 – Allowable Costs The BOCES concurs with the finding 2025-001. Corrective Action: The BOCES will implement the following corrective actions to be completed by November 30, 2025: 1. The BOCES will develop and implement new written policies and procedures for time and effort reporting...
Finding 2025-001 – Allowable Costs The BOCES concurs with the finding 2025-001. Corrective Action: The BOCES will implement the following corrective actions to be completed by November 30, 2025: 1. The BOCES will develop and implement new written policies and procedures for time and effort reporting. 2. All grant-funded employees will receive training on the new procedures. 3. The BOCES will implement a new system to track and certify employee time. Contact Person: Daniel Henner, Business Administrator (315) 796-9902 dhenner@herkimer-boces.org
Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: Management will implement formal governance procedures to monitor and maintain compliance with the required board composition. Manage...
Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: Management will implement formal governance procedures to monitor and maintain compliance with the required board composition. Management will work with the Board of Directors to ensure that Target Population seats are filled timely and that vacancies are tracked and addressed promptly. The Organization will periodically review board membership throughout the year to verify continued compliance with applicable CSBG requirements. Official Responsible for Ensuring CAP: The Board of Directors /Chief Executive Officer will be responsible for implementing the CAP. Planned Completion Date for CAP: The Organization will implement the recommended changes immediately. Plan to Monitor Completion of CAP: The Board of Directors will be monitoring this corrective action plan.
Federal Agency Name: Department of State Assistance Listing Number: 19.510 Program Name: U.S. Refugee Admissions Program Special Tests and Provisions Finding Summary: a. One instance was identified where documentation for both the initial home visit and the 30-day follow-up home visit was missing fr...
Federal Agency Name: Department of State Assistance Listing Number: 19.510 Program Name: U.S. Refugee Admissions Program Special Tests and Provisions Finding Summary: a. One instance was identified where documentation for both the initial home visit and the 30-day follow-up home visit was missing from the participant file. No case activity or other documentation was able to be provided to indicate that these visits were conducted in accordance with the federal program. b. One instance was identified where an expense was paid and reimbursed under the grant without evidence of a formal request, invoice support, review, or approval. Responsible Individuals: Nathan Beyer, Staci Jonson, Dana Boraas Corrective Action Plan: Procedures will be reviewed with staff to ensure staff are fully trained on required documentation needed to maintain a complete case file, and that documentation is being completed and retained. Anticipated Completion Date: December 31, 2025
Federal Agency Name: Department of State Assistance Listing Number: 19.510 Program Name: U.S. Refugee Admissions Program Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: Two instances were identified where the approval over the expense occurred after the check was...
Federal Agency Name: Department of State Assistance Listing Number: 19.510 Program Name: U.S. Refugee Admissions Program Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: Two instances were identified where the approval over the expense occurred after the check was written. Responsible Individuals: Nathan Beyer, Staci Jonson, Dana Boraas Corrective Action Plan: Procedures will be reviewed with staff to ensure staff are fully trained on the proper sequence of approval and release of checks. Where appropriate, procedures may be modified to ensure proper approval is obtained and documented, prior to checks being delivered to clients. Anticipated Completion Date: December 31, 2025
Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.566 Program Name: Refugee and Entrant Assistance - State Administered Programs Eligibility Finding Summary: Two instances were identified where the participant was underpaid based upon eligibility for one mont...
Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.566 Program Name: Refugee and Entrant Assistance - State Administered Programs Eligibility Finding Summary: Two instances were identified where the participant was underpaid based upon eligibility for one month. Responsible Individuals: Nathan Beyer, Staci Jonson, Dana Boraas Corrective Action Plan: Procedures will be reviewed with staff to ensure staff are fully trained on how to calculate eligibility, and to ensure proper documentation is retained when there are barriers to determining that eligibility. Anticipated Completion Date: December 31, 2025
The Greenwood Housing Authority will used the most recent General Depository Agreement for the financial institutions. The Executive Director will ensure that the documentation is appropriate relative to timing.
The Greenwood Housing Authority will used the most recent General Depository Agreement for the financial institutions. The Executive Director will ensure that the documentation is appropriate relative to timing.
December 29, 2025 Bay County Council on Aging, Inc. Management’s Corrective Action Plan For Fiscal Year Ended March 31, 2025 Finding Number: 2025-001 Planned Corrective Action: On March 31, 2025, the Department of Commence changed software vendors. In this system the program gives a suggested benefi...
December 29, 2025 Bay County Council on Aging, Inc. Management’s Corrective Action Plan For Fiscal Year Ended March 31, 2025 Finding Number: 2025-001 Planned Corrective Action: On March 31, 2025, the Department of Commence changed software vendors. In this system the program gives a suggested benefit amount that the household will receive. The Organization's staff member has to confirm the commitment, but the software will not allow a household to receive more than they are eligible for. Per the requirements of the new software system, the client is responsible for completing the application and uploading any required supporting documentation. The Organization is responsible for verifying the information is correct based on the supporting documentation prior to the release of the funds to the client. Anticipated Completion Date: 3/31/2025 Responsible Contact: Karen Coffman
Condition: The property is not utilizing the Replacement Reserve as intended and is instead paying for costs out of the operating account. Action Plan: Please see below the new process ensuring replacement reserve requests are being made in a timely manner: 1) Quarterly Assessment: Quarterly review ...
Condition: The property is not utilizing the Replacement Reserve as intended and is instead paying for costs out of the operating account. Action 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: 4/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Condition: Lack of review and approvals on time allocated and charged to the property. Action Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the a...
Condition: Lack of review and approvals on time allocated and charged to the property. Action Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensure that the Director of Affordable Housing submits an allocation sheet each pay period. The COO will check the allocation sheet for accuracy before approving the allocation sheet and submitting to Payroll for processing. The allocation sheet submitted will include detailed information on the job duties performed during that pay period by the staff member submitting the allocation sheet. Completion Date: 6/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Condition: HUD forms must be certified by an authorized user. Action Plan: Please see below the new process ensuring that all HUD forms are certified by an authorized user: 1) Tracking System: A system has been implemented to monitor certifier assignments and send reminders for updates. 2) Training ...
Condition: HUD forms must be certified by an authorized user. Action Plan: Please see below the new process ensuring that all HUD forms are certified by an authorized user: 1) Tracking System: A system has been implemented to monitor certifier assignments and send reminders for updates. 2) Training & Oversight: Staff training will be enhanced, and management will increase oversight to ensure compliance. 3) Monitoring and Accountability: Management will regularly review the certification process to ensure all forms are signed by the appropriate certifiers and to verify that all necessary updates are made promptly. Completion Date: 7/1/2024 Contact: Jackie Oliveira-Director of Affordable Housing
Condition: The property is not utilizing the Replacement Reserve as intended and is instead paying for costs out of the operating account. Action Plan: Please see below the new process ensuring replacement reserve requests are being made in a timely manner: 1) Quarterly Assessment: Quarterly review ...
Condition: The property is not utilizing the Replacement Reserve as intended and is instead paying for costs out of the operating account. Action 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: 5/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Condition: Lack of review and approvals on time allocated and charged to the property. Action Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the a...
Condition: Lack of review and approvals on time allocated and charged to the property. Action Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensure that the Director of Affordable Housing submits an allocation sheet each pay period. The COO will check the allocation sheet for accuracy before approving the allocation sheet and submitting to Payroll for processing. The allocation sheet submitted will include detailed information on the job duties performed during that pay period by the staff member submitting the allocation sheet. Completion Date: 6/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Condition: HUD forms must be certified by an authorized user. Action Plan: Please see below the new process ensuring that all HUD forms are certified by an authorized user: 1) Tracking System: A system has been implemented to monitor certifier assignments and send reminders for updates. 2) Training ...
Condition: HUD forms must be certified by an authorized user. Action Plan: Please see below the new process ensuring that all HUD forms are certified by an authorized user: 1) Tracking System: A system has been implemented to monitor certifier assignments and send reminders for updates. 2) Training & Oversight: Staff training will be enhanced, and management will increase oversight to ensure compliance. 3) Monitoring and Accountability: Management will regularly review the certification process to ensure all forms are signed by the appropriate certifiers and to verify that all necessary updates are made promptly. Completion Date: 7/1/2024 Contact: Jackie Oliveira-Director of Affordable Housing
This finding is due to the District not having the proper controls in place to prevent, detect, or correct an incorrect monthly meal claim. The month that had the incorrect meal claim used incomplete Z-Reports which resulted in the meal claim being submitted for less than it should have been. The pe...
This finding is due to the District not having the proper controls in place to prevent, detect, or correct an incorrect monthly meal claim. The month that had the incorrect meal claim used incomplete Z-Reports which resulted in the meal claim being submitted for less than it should have been. The persons responsible for the corrective action are Lisa Newton, the Food Service Director and Corey Bordo, the Director of Business and Finance. The anticipated completion date of the corrective action plan is immediate. The plan for monitoring adherence is the Food Service Director will ensure that all meal counts are final on the Z-Report before the claim requests are made.
Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend that the Authority implements controls to ensure HUD-50058 recertifications are uploaded to PIC. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken i...
Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend that the Authority implements controls to ensure HUD-50058 recertifications are uploaded to PIC. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The 3 exceptions have been uploaded. PHA’s Information Systems Management (ISM) Department has implemented a secondary quality control measure to confirm that all 50058 files have been successfully uploaded; the Vice President of Application Support will conduct routine and regular reviews of 50058 file uploads to ensure that transactions have been submitted and uploaded timely. Name(s) of the contact person(s) responsible for corrective action: Cynthia Hallman, Vice President – Application Support Planned completion date for corrective action plan: Upload is complete, quality control check has been implemented and ongoing.
2025-004 Eligibility Contact Person – Lora Papacheck, CEO Planned Corrective Action – Management agrees with the recommendation and will review their policies and procedures to ensure all applications are maintained and the file checklist is completed. Completion Date – Fiscal year 2026
2025-004 Eligibility Contact Person – Lora Papacheck, CEO Planned Corrective Action – Management agrees with the recommendation and will review their policies and procedures to ensure all applications are maintained and the file checklist is completed. Completion Date – Fiscal year 2026
2025-003 Allowable Costs/Cost Principles Contact Person – Lora Papacheck, CEO Planned Corrective Action – Management agrees with the recommendation and will review their policies and procedures to ensure out-of-state travel is approved in advance and documentation is kept supporting the approval. Co...
2025-003 Allowable Costs/Cost Principles Contact Person – Lora Papacheck, CEO Planned Corrective Action – Management agrees with the recommendation and will review their policies and procedures to ensure out-of-state travel is approved in advance and documentation is kept supporting the approval. Completion Date – Fiscal year 2026
Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the USDA program reserve fund. Corrective Action Plan: Manage...
Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the USDA program reserve fund. Corrective Action Plan: Management will ensure a review separate from the preparer of the reconciliation for the program's reserve fund is completed with formal documentation noting the review. The Business Office Manager will reconcile the bank statement and will sign off on the bank statement, along with the Administrator for the USDA Loan Reserve Bank Account. Responsible Individuals: Gerry Leadbetter, Administrator Anticipated Completion Date: January 2026
The first step was to hire a director of finance (the 3rd hirer in the past 2 years passed away suddenly) which was completed in February 2025. The second step was to hire third party CPA consultants familiar with accounting system to correct activity and design of system for ongoing use. Finally, t...
The first step was to hire a director of finance (the 3rd hirer in the past 2 years passed away suddenly) which was completed in February 2025. The second step was to hire third party CPA consultants familiar with accounting system to correct activity and design of system for ongoing use. Finally, training of support staff and monitoring of the monthly accounting procedures completed upon correction of historical activity.
Replacement Reserve Monthly Deposits Not Made Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should made the required deposits monthly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in res...
Replacement Reserve Monthly Deposits Not Made Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should made the required deposits monthly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will make the required deposits monthly as cash flow allows. Name(s) of the contact person(s) responsible for corrective action: Mary Gilberts, Management Agent Planned completion date for corrective action plan: June 2026
Finding Number: 2025-001 Condition: The Organization deposited prior year surplus cash 56 days after the deadline stated in the Real Estate Assessment Center’s Summary of Financial Reporting and Auditing Guidance for HUD (FRAG Guide) under Section 2.8. Planned Corrective Action: Management has ackno...
Finding Number: 2025-001 Condition: The Organization deposited prior year surplus cash 56 days after the deadline stated in the Real Estate Assessment Center’s Summary of Financial Reporting and Auditing Guidance for HUD (FRAG Guide) under Section 2.8. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management deposited the surplus cash amount of $39,601 into residual receipts on November 25, 2024. Contact person responsible for corrective action: Tyler Luce Anticipated Completion Date: November 25, 2024
Finding Number: 2025-001 Condition: Withdrawals totaling $13,846 were made from the replacement reserve without HUD authorization. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Mana...
Finding Number: 2025-001 Condition: Withdrawals totaling $13,846 were made from the replacement reserve without HUD authorization. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management has deposited the underfunded amount of $13,846 to the replacement reserve account on July 10, 2025. Contact person responsible for corrective action: Tyler Luce Anticipated Completion Date: July 10, 2025
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