Corrective Action Plans

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Internal Control Over Reporting Department of Human Services – Grants to States for Medicaid – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit f...
Internal Control Over Reporting Department of Human Services – Grants to States for Medicaid – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure that all reports are reviewed prior to submission. Names of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2026
Findings #2025-004 and #2025-006 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, 93.566, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Passed through Texas Office for Refugees: 10/01/24 –...
Findings #2025-004 and #2025-006 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, 93.566, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Passed through Texas Office for Refugees: 10/01/24 – 09/30/25, FFY2025-27946V-ASA RSS, 10/01/24 – 09/30/25, FFY2025-27946V-AUSAA-RSS, 10/01/24 – 09/30/25, FFY2025-27946V-CMA, 10/01/24 – 09/30/25, FFY2025-27946V-RSS, Passed through United States Conference of Catholic Bishops: 10/01/24 – 09/30/25, 25RSI13A, Passed through U. S. Committee for Refugees: 10/01/24 – 09/30/25, RHP-2025-YMCA-Houston TX-03, 93.567, Refugee and Entrant Assistance Voluntary Agency Programs, Passed through U. S. Committee for Refugees and Immigrants: 10/01/24 – 09/30/25, 2502VARVMG, 10/01/23 – 09/30/24, 2402VARVMG, 93.676, Unaccompanied Alien Children Program, Passed through U. S. Committee for Refugees and Immigrants: 01/01/25 – 12/31/25, 90ZU0630-02. Condition and context: During our testing of the accuracy of accounts payable cutoff and the testing of allowable costs charged to major programs, the following exceptions were identified for expenses recorded in the incorrect period: 3 of 19 subsequent disbursement transactions tested were recorded in the incorrect accounting period. Refugee and Entrant Assistance State/Replacement Designee Administered Programs (ALN 93.566) – 3 out of 40 transactions tested were recorded to the incorrect accounting period. Unaccompanied Alien Children Program (ALN 93.676) – 1 out 40 transactions tested was recorded in the incorrect accounting period. Refugee and Entrant Assistance Voluntary Agency Programs (ALN 93.567) – 1 out of 40 transactions tested was recorded in the incorrect accounting period. Recommendation: Policies and procedures should be enhanced for proper identification of the period that expenses relate to so that expenses will be recorded in the correct accounting period for financial statement reporting and for billing allowable costs to federal programs. Planned corrective action: Management acknowledges the deficiency identified related to the precision of procedures to ensure expenses are recorded in the appropriate accounting period. Processes were in place and operated to identify and record expenses in the correct period, and management’s review procedures are designed to capture all material items for financial reporting and program compliance purposes. The exceptions identified through audit testing represent a limited number of timing differences in a high-volume environment, primarily related to the timing of invoice receipt and processing, and were not material individually or in the aggregate. These items were recorded in the subsequent period in the normal course of operations and do not reflect a systemic breakdown in controls. In response, management has reinforced month-end cutoff procedures, including enhanced review of subsequent disbursements and clearer expectations around accrual identification and invoice timing. Management will continue to monitor cutoff procedures to ensure expenses are recorded in the appropriate period with an appropriate level of precision while maintaining timely vendor payment practices. Responsible officer: Lauren Rome, VP of Financial Operations/Interim CFO. Estimated completion date: June 15, 2026
Implement cross training of staff member, maintain updated procedures for tasks, and establish backup coverage for critical reporting functions to mitigate the impact of future staffing changes in the reporting compliance process. Anticipated completion date: December 31, 2026. Responsible contact: ...
Implement cross training of staff member, maintain updated procedures for tasks, and establish backup coverage for critical reporting functions to mitigate the impact of future staffing changes in the reporting compliance process. Anticipated completion date: December 31, 2026. Responsible contact: Mike Gagliardi, Administrator.
Statement of Condition: During our testing of participant eligibility for the WIOA Cluster, we identified an instance in which a male participant subject to Selective Service requirements was not registered with the Selective Service System, and no evidence of registration verification or documented...
Statement of Condition: During our testing of participant eligibility for the WIOA Cluster, we identified an instance in which a male participant subject to Selective Service requirements was not registered with the Selective Service System, and no evidence of registration verification or documented exemption was maintained in the participant file. Management Response and Corrective Action Plan: Management agrees with the recommendation and has developed a guideline in which a participant is not to be co-enrolled in WIOA Youth while being enrolled in another youth program. Responsibility of: Chief Finance and Admin Officer, Sherri Emitte Planned Implementation Date of Corrective Action Plan: 2026 Audit
Statement of Condition: During our testing of compliance with requirements applicable to major federal programs, we noted that the entity did not have formal, consistently applied review and approval controls over key compliance areas. Specifically, evidence of supervisory review and approval was no...
Statement of Condition: During our testing of compliance with requirements applicable to major federal programs, we noted that the entity did not have formal, consistently applied review and approval controls over key compliance areas. Specifically, evidence of supervisory review and approval was not consistently documented for compliance-related transactions. As a result, review procedures appear to be informal, inconsistent, or reliant on individual practices rather than standardized, documented controls. Management Response and Corrective Action Plan: Management agrees with the recommendation and has developed a much more stringent review and approval process. Responsibility of: Chief Finance and Admin Officer, Sherri Emitte Planned Implementation Date of Corrective Action Plan: 2026 Audit
2025-002: Reporting Submissions Not Performed Timely Federal Department: Department of Housing and Urban Development Assistance Listing #: 14.251 Internal Controls Significant Deficiency & Noncompliance Category of Finding – Reporting Name of contact person: Leah Cameron, Director of Supportive Serv...
2025-002: Reporting Submissions Not Performed Timely Federal Department: Department of Housing and Urban Development Assistance Listing #: 14.251 Internal Controls Significant Deficiency & Noncompliance Category of Finding – Reporting Name of contact person: Leah Cameron, Director of Supportive Services Corrective Action: Clare Housing will complete the following corrective action steps: • Clare Housing will establish a centralized reporting calendar for all grants that includes all required reports, due dates, and responsible staff. • Clare Housing will clearly assign ownership for each report, including primary and backup staff. • Clare Housing will utilize automated reminders (e.g., calendar alerts or task management tools) at key intervals prior to due dates. • Clare Housing will track report status (in progress, under review, submitted) to ensure visibility. • The Director of Supportive Services will monitor overall reporting compliance and conduct periodic file reviews. Clare Housing will ensure reporting requirements are met by establishing calendar reminders for all reporting requirements. Calendar reminders will include relevant staff, including but not limited to, the Director of Finance and the Director of Supportive Services. The Director of Supportive Services and Director of Finance will ensure submission of any prepared reports in the DRGR (or other relevant reporting) system by the appropriate due date. Completion Date: Creation of the centralized reporting calendar and tracking system and periodic file reviews will be by August 1, 2026.
Recommendation: We recommend that Eastern Lancaster County School District implement procedures to ensure that SNP Claim for Reimbursement Summary reports are independently reviewed and approved prior to submission to Program Electronic Application and Reimbursement System (PEARS). This review shoul...
Recommendation: We recommend that Eastern Lancaster County School District implement procedures to ensure that SNP Claim for Reimbursement Summary reports are independently reviewed and approved prior to submission to Program Electronic Application and Reimbursement System (PEARS). This review should be performed by an individual who is not involved in the preparation of the reports and evidence of the review should be documented. School District Response: (Corrective Action) Eastern Lancaster County School District will implement formal internal control procedures requiring review and documented approval of all SNP Claim for Reimbursement Summary reports prior to submission in PEARS. The following procedures will be implemented: 1. The Director of Food Services will prepare the monthly SNP Claim for Reimbursement Summary report and compile all supporting meal count documentation. 2. Prior to submission, the Administrative Assistant to the Director of Food Services or another designated individual independent of the preparation process will: o Review the claim for mathematical accuracy. o Verify meal counts against supporting documentation. o Confirm claims are submitted within required timelines. 3. Evidence of the review and approval will be documented through: o Signature or electronic approval on the reimbursement summary report. o Retention of supporting documentation in accordance with federal and state record retention requirements. 4. A written standard operating procedure (SOP) outlining these review and approval responsibilities will be developed and communicated to applicable personnel. 5. The Chief of Finance and Operation will periodically monitor compliance with the procedure to ensure controls remain effective. Anticipated Completion Date: The corrective action procedures will be fully implemented by June 1, 2026. Responsible Person for the Corrective Action: Keith D. Ramsey, Chief of Finance and Operations
2025-003 Eligibility Finding Type: Significant deficiency in Internal Controls over Compliance and Compliance Federal Program Title and AL Number: The Food Distribution Cluster (10.565, 10.568, 10.569). Criteria: Per Title 7 CFR § 247.8, to apply for or to be recertified for CSFP benefits, the appli...
2025-003 Eligibility Finding Type: Significant deficiency in Internal Controls over Compliance and Compliance Federal Program Title and AL Number: The Food Distribution Cluster (10.565, 10.568, 10.569). Criteria: Per Title 7 CFR § 247.8, to apply for or to be recertified for CSFP benefits, the applicant or caretaker of the applicant must be informed of his or her rights and responsibilities, in accordance with § 247.12, the local agency must ensure that the applicant or caretaker signs the application form. Condition and context: As part of our eligibility testing, and in order to determine compliance with the requirements, we verified that the CSFP participants had completed and signed applications or recertifications prior to receiving food distributions. For four out of 32 non-statistical samples, the application was completed but did not have the participants' signature. Cause: The Food Bank did not have controls in place to ensure the participant signatures were received prior to providing food assistance to the individual. Effect: The Food Bank was not able to demonstrate compliance with Title 7 CFR § 247.8. Questioned Costs: None Repeat finding: No Recommendation: We recommend the Food Bank implement controls to ensure CSFP applications and recertifications are signed by the applicant prior to the individual receiving food. Views of responsible officials and planned corrective actions: Management concurs with the finding and recommendation. Please see the attached corrective action plan. Management Response and Planned Corrective Action: Criteria: Per Title 7 CFR § 247.8, to apply for or to be recertified for Commodity Supplemental Food Program (“CSFP”) benefits, the applicant or caretaker of the applicant must be informed of his or her rights and responsibilities, in accordance with § 247.12, the local agency must ensure that the applicant or caretaker signs the application form. The Los Angeles Regional Food Bank (“Food Bank”) has submitted a request to “Oasis Insights”, the Food Bank’s software vendor utilized for CSFP, to reinstate mandatory field validation, or a “hard stop”, on CSFP applications to prevent case progression or assistance issuance when required signatures have not been captured. The Food Bank will verify that the mandatory field validation feature has been reinstated. Additionally, the Food Bank’s CSFP Program Manager will ensure that all Food Bank employees responsible for overseeing CSFP will be provided with retraining in the area of CSFP eligibility requirements. The Director of Compliance and Administration will verify that CSFP applications through Oasis are unable to progress forward without a required signature and that the aforementioned CSFP eligibility training has been completed. The Food Bank will complete these corrective actions on or before June 30, 2026. Individuals responsible for corrective action: Elizabeth Cervantes – Sr. Director of Product Acquisition and Agency Relations 323.974.0073 Hilda Ayala – Sr. Director of Programs and Policy 323.353.0114 Steven Meisberger – Chief Financial Officer 323.318.0319
Finding 2025-005 Lack of Internal Control over Special Tests and Provisions- Character Investigations Name of Contact Person: Alexis Russell, Human Resource Director Corrective Action: Background check verification will be added into the employee onboarding process for all Annette Island Service Uni...
Finding 2025-005 Lack of Internal Control over Special Tests and Provisions- Character Investigations Name of Contact Person: Alexis Russell, Human Resource Director Corrective Action: Background check verification will be added into the employee onboarding process for all Annette Island Service Unit employees to ensure required character investigations are completed and documented for all positions subject to Indian Child Protection and Family Violence Prevention Act requirements. In addition, Human Resources will conduct periodic internal reviews of personnel files to indentify and address any missing background check documentation for current employees Proposed Completion Date: Implemented in FY2026, ongoing monitoring in place.
Finding 1217346 (2025-004)
Material Weakness 2025
Internal Control Over Reporting Department of Human Services – Grants to States for Medicaid – Assistance Listing No. 93.778 Recommendation: We recommend the county implement processes and procedures to ensure all reports have a timely review documented by someone other than the preparer. Explanatio...
Internal Control Over Reporting Department of Human Services – Grants to States for Medicaid – Assistance Listing No. 93.778 Recommendation: We recommend the county implement processes and procedures to ensure all reports have a timely review documented by someone other than the preparer. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: County will continue to train staff to ensure they are aware of the requirements. Names of the contact person responsible for corrective action: Denise Gaida, Auditor- Treasurer Planned completion date for corrective action plan: December 31, 2026
Finding 2025-002- Eligibility- Significant Deficiency in Internal Controls over Compliance and Non-Compliance Federal Program: Home Investment Partnerships Program (HOME) Assistance Listing Number: 14.239 Year(s): 2025 Federal Agency: Department of Housing and Urban Development (HUD) Pass-Through Ag...
Finding 2025-002- Eligibility- Significant Deficiency in Internal Controls over Compliance and Non-Compliance Federal Program: Home Investment Partnerships Program (HOME) Assistance Listing Number: 14.239 Year(s): 2025 Federal Agency: Department of Housing and Urban Development (HUD) Pass-Through Agencies: Idaho Housing and Finance Association Responsible Party: Jeanne Stromberg, Major - Divisional Finance Secretary-Cascade Division 916-501-6374 RESPONSE: Management will implement a review and approval process to ensure all documentation for applications is maintained in the file and that all applications that are eligible tor participation are properly approved. Effective Date: November 2026
2025-005: WAGE RATE REQUIREMENTS Program: Impact Aid Federal Assistance Listing Number: 84.041 Federal Agency: U.S. Department of Education Pass-Through Agency: Direct award Grantor Number: Not applicable Questioned Costs: $-0- Type of Finding: Noncompliance (Other Matter), significant deficiency in...
2025-005: WAGE RATE REQUIREMENTS Program: Impact Aid Federal Assistance Listing Number: 84.041 Federal Agency: U.S. Department of Education Pass-Through Agency: Direct award Grantor Number: Not applicable Questioned Costs: $-0- Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Compliance Requirement: N. Special Tests and Provisions – Wage Rate Requirements Repeat Finding: Yes. Same as finding 2024-001 and 2023-002. Criteria or Specific Requirement: Federal regulations require that contractors and subcontractors performing work on federally funded construction projects pay laborers and mechanics wages at rates not less than those prevailing on similar projects in the locality. These requirements are established under the Davis-Bacon Act and incorporated into federal grant compliance requirements under 2 CFR Part 200. Adequate monitoring of compliance with these wage requirements is required to ensure that workers are being paid correctly per 29 CFR 5.5 compliance provisions. Per 2 CFR section 200.303(a), a non-Federal entity must establish and maintain effective internal control over Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should comply with guidance in “Standards for Internal Control in Federal Government” issued by the Comptroller General of the United States or the “Internal Control-Integrated Framework,” issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: During our testing for one of 2 contractors that were tested and funded under the Impact Aid program, we noted that the District did not obtain or review certified payroll reports from contractors to verify compliance with federal prevailing wage requirements. As a result, the District could not demonstrate that contractors complied with required wage provisions for the sampled projects. Corrective Action: The District will ensure wage rate requirements are maintained for all vendors as appropriate under Uniform Guidance and the provision of the Davis Bacon Act. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Kay Morris, Superintendent
By expanding our internal and/or contracted accounting capacity and updating internal controls and accounting processes to include these new roles in the monthly and annual workflow, the Organization will be in better position to perform timely reconciliations and adjustments to federal grant activi...
By expanding our internal and/or contracted accounting capacity and updating internal controls and accounting processes to include these new roles in the monthly and annual workflow, the Organization will be in better position to perform timely reconciliations and adjustments to federal grant activity, ensuring timely filling of the data collection form and single audit package.
Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority strengthen internal controls over HQS enforcement by implementing procedures to track and monitor HQS deficiencies and required correction timelines. Explanation of disagreement with audit f...
Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority strengthen internal controls over HQS enforcement by implementing procedures to track and monitor HQS deficiencies and required correction timelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PBCHA has made significant improvements in inspection compliance and will continue to monitor its third-party inspection vendor to ensure timely submission of inspection reports. The agency will utilize Yardi and other centralized tracking systems to monitor inspection due dates and follow-up activities, ensuring inspections are completed in accordance with HUD requirements. PBCHA will also provide ongoing staff training to reinforce NSPIRE requirements and compliance expectations. Name(s) of the contact person(s) responsible for corrective action: Yvette Bembry Planned completion date for corrective action plan: December 31, 2026
Finding 2025-003: Period of Performance – Significant deficiency in internal controls over compliance and compliance finding. Management Response The agency has added another level of review for Requests for Reimbursement (RFRs) to improve internal controls. Effective 10.01.2025, grant expense charg...
Finding 2025-003: Period of Performance – Significant deficiency in internal controls over compliance and compliance finding. Management Response The agency has added another level of review for Requests for Reimbursement (RFRs) to improve internal controls. Effective 10.01.2025, grant expense charges are processed as follows: 1. Finance Assistant creates grant Request for Reimbursement (RFR). Upon completion of the RFR, theAssistant signs the RFR as completed, then submits completed RFR along with supportingdocumentation to the EVP of Finance. Formerly, the creation of the RFR was being done by the EVP of Finance, with the addition of staff, we were able to relocate those duties to Finance Assistance in the Fall of 2025. 2. The EVP of Finance reviews the RFR for correct calculations and if the appropriate supportingdocumentation is attached. The EVP of Finance signs the RFR, then presents it to the ChiefOperating Officer for final approval. 3. Chief Operating Officer receives RFR from EVP of Finance, reviews RFR and approves for submissionto the Grantor or sends back for corrections. Adding a staff member in the Finance department allowed us to add another level of approval. In addition, notations have been made on all internal grant tracking documents, as to the start of each grant period. A payroll pay calendar is accessible to verify the exact dates covered on a pay period.
The Organization acknowledges and concurs with the auditor’s finding as discussed within the Schedule of Findings and Questioned Costs for the year-ended September 30, 2025. During the audit for PTV’s fiscal year 2025, it was determined that we should add an additional layer of confirmation to our a...
The Organization acknowledges and concurs with the auditor’s finding as discussed within the Schedule of Findings and Questioned Costs for the year-ended September 30, 2025. During the audit for PTV’s fiscal year 2025, it was determined that we should add an additional layer of confirmation to our approval process. Currently, the President reviews invoices prior to signing the checks, thereby signaling approval. Moving forward, in addition to this review, the President will also confirm approval by initialing the invoice itself. Beyond this initial next step, PTV will also review its current Fiscal Policy to consider implementation of an approval process that allows other authorized approvers the authority to review expenses up to certain thresholds. Policy development at this level requires Finance Committee involvement and full Board approval, so it may take several months to fully implement a new process. We appreciate the opportunity to continue to strengthen PTV’s internal controls and financial operations.
The Organization acknowledges and concurs with the auditor’s finding as discussed within the Schedule of Findings and Questioned Costs for the year-ended September 30, 2025. During the audit for PTV’s fiscal year 2025, it was determined that we should add an additional layer of confirmation to our a...
The Organization acknowledges and concurs with the auditor’s finding as discussed within the Schedule of Findings and Questioned Costs for the year-ended September 30, 2025. During the audit for PTV’s fiscal year 2025, it was determined that we should add an additional layer of confirmation to our approval process. Currently, the President reviews invoices prior to signing the checks, thereby signaling approval. Moving forward, in addition to this review, the President will also confirm approval by initialing the invoice itself. Beyond this initial next step, PTV will also review its current Fiscal Policy to consider implementation of an approval process that allows other authorized approvers the authority to review expenses up to certain thresholds. Policy development at this level requires Finance Committee involvement and full Board approval, so it may take several months to fully implement a new process. We appreciate the opportunity to continue to strengthen PTV’s internal controls and financial operations.
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Supportive Housing for the Elderly Section 232 ALN Number: 14.129 Award Period: Year Ended December 31, 2025 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria ...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Supportive Housing for the Elderly Section 232 ALN Number: 14.129 Award Period: Year Ended December 31, 2025 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: HUD requires a signed management fee agreement when such transactions take place. Condition: Unallowed related party transactions were identified in 2025. Context: Affiliate dues were booked to the Home's cash clearing account as a credit for $400,000 with the understanding that these fees would qualify as a service contract rather than a management fee. However, due to the cash infused into the program by The Carmelite System, the $400,000 will not be noted as questioned costs needing to be repaid into the project. Recommendation: The Home should adhere to the Regulatory Agreement and obtain HUD’s approval prior to taking any actions specifically precluded in the Regulatory Agreement. Action taken in response to finding: There is no disagreement with the audit finding. Management will work to obtain proper approval going forward. If the U.S. Department of Housing and Urban Development has questions regarding this schedule, please call Corrinne Schindler at 518-537-7500 or CSchindler@CarmeliteSystem.org.
Management agrees with the finding and acknowledges that internal controls over inventory issuance were not consistently followed by an individual. While procedures existed requiring documentation of pick tickets, compliance with these procedures was not adequately enforced on a small number of tran...
Management agrees with the finding and acknowledges that internal controls over inventory issuance were not consistently followed by an individual. While procedures existed requiring documentation of pick tickets, compliance with these procedures was not adequately enforced on a small number of transactions. The Cooperative has begun strengthening its internal control processes to ensure that all inventory withdrawals are properly authorized and documented prior to release. In addition, management will implement monitoring procedures, including periodic reviews of inventory documentation, to ensure compliance with established controls. Training will also be provided to all relevant personnel to reinforce proper procedures and the importance of adherence to internal control requirements. Management expects these corrective actions to be fully implemented by May 15, 2026.
Views of Responsible Officials and Planned Corrective Action: Responsible officials acknowledge the finding and agree that documentation supporting student removals from the adjusted cohort was not maintained timely in all instances. Management stated that it will implement enhanced procedures and s...
Views of Responsible Officials and Planned Corrective Action: Responsible officials acknowledge the finding and agree that documentation supporting student removals from the adjusted cohort was not maintained timely in all instances. Management stated that it will implement enhanced procedures and supervisory review processes to ensure required documentation is obtained and retained timely for all applicable students going forward.
Management Response: Management concurs with the findings. OlyCAP recognizes the importance of maintaining complete and accurate tenant eligibility documentation to demonstrate compliance with HUD program requirements. The missing background verification documentation identified during the audit app...
Management Response: Management concurs with the findings. OlyCAP recognizes the importance of maintaining complete and accurate tenant eligibility documentation to demonstrate compliance with HUD program requirements. The missing background verification documentation identified during the audit appears to be the result of incomplete lease up processes at project inception in 2005. While management believes eligibility determinations were appropriately made, supporting documentation was not obtained in the early period of the project. Corrective Action Plan: 1. OlyCAP has implemented a standardized tenant file checklist identifying all required eligibility and compliance documentation, including background verification records, income documentation, lease agreements, and other required tenant file components. 2. Housing program staff has been trained on file documentation requirements, records retention standards, and file review procedures. 3. Management conducted a comprehensive review in 2024 of all current tenant files to identify missing documentation. 4. Supervisory file reviews are conducted on all tenant files at lease up using the standardized checklist to verify that required documentation is complete and maintained in accordance with program requirements. These corrective actions are intended to strengthen internal controls over tenant eligibility documentation and ensure ongoing compliance with HUD requirements. Anticipated Completion Date: July 1, 2026 Responsible officials: .Executive Director .Housing Director .Housing Program Managers .Compliance and Quality Assurance Staff
Corrective Action Plan For the Year Ended June 30, 2025 Finding: 2025-003 Inaccurate Resources Entry Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2025-004 Inaccurate Resources Entry Name of contact person: Corrective Action: Section III - Federal Award Findings and Q...
Corrective Action Plan For the Year Ended June 30, 2025 Finding: 2025-003 Inaccurate Resources Entry Name of contact person: Corrective Action: Proposed Completion Date: Finding: 2025-004 Inaccurate Resources Entry Name of contact person: Corrective Action: Section III - Federal Award Findings and Question Costs Darren Phillips, Quality Assurance and Program Integrity Supervisor We are building a training slideshow presentation to provide tenured caseworkers refresher training for all of the Internal Error findings. This will cover Incorrect Resources, Incorrect Income, Incorrect HH and Residency issues. The SSI expartes that were in error have been completed as of 12/10/2025. We will cover the use of NCFAST reports to ensure that they are worked in a timely manner. A greater emphasis will be placed during training of new hires in the areas of the errors found. Supervisors will provide policy updates and review the income and recertification policies in the Monthly Unit Meetings. The Medicaid Division Director will meet with the Medicaid supervisors to address the untimely reviews and put a plan into place to work them in a timely manner. A review of the Recertification process for Family and Children's Medicaid in terms of timeliness and pending notices will also be accomplished. Training will be provided by 2/28/2026 for all Medicaid personnel. Darren Phillips, Quality Assurance and Program Integrity Supervisor We are currenty building a training slideshow presentation to provide tenured caseworkers refresher training on how to update income on cases. The training will cover Self-Employment, the use of pay stubs and pulling income from OVS and TWN. The training will cover both error findings, Incorrect Income and Inadequate Request for Income. A greater emphasis will be placed on the training of new hires for the areas of the errors found. A Desk Reference will be created to assist caseworkers with their duties. Supervisors will provide policy updates and review the income and recertification policies in their Monthly Unit Meetings. The Medicaid Director will meet with the Medicaid Supervisors to discuss the Untimely Reviews to ensure that cases are completed in a timely manner. A review of the Recertification process for Family and Children's Medicaid in terms of timeliness and pending notices will also be accomplished. 230
Name of Contact Person: Kris Hernandez, Director of Social Services Corrective Action: The County has worked with NCDHHS to correct errors in the audit and they have issued a revised notice. The County has further achieved eligibility accuracy rates of 100% in both standards as a result of the immed...
Name of Contact Person: Kris Hernandez, Director of Social Services Corrective Action: The County has worked with NCDHHS to correct errors in the audit and they have issued a revised notice. The County has further achieved eligibility accuracy rates of 100% in both standards as a result of the immediate accuracy improvement approach taken with OCPI audit staff. “Kudos to your staff on the improvements” has been a forwarded comment. Date of completion: September 25, 2025
2025-002 Cash Management Corrective action planned: Management will implement controls over all draws from the Payment Management System to minimize the time elapsed between the drawdown of funds from PMS and the payment for expenditures. The controls will incorporate the following: Prepare a detail...
2025-002 Cash Management Corrective action planned: Management will implement controls over all draws from the Payment Management System to minimize the time elapsed between the drawdown of funds from PMS and the payment for expenditures. The controls will incorporate the following: Prepare a detailed listing of expenditures claimed for reimbursement for each drawdown request. The expenditures listing will be reviewed by appropriate personnel to ensure cash payments for the expenditure are made before the date of the draw or within a reasonable time after the draw. Drawdowns are authorized and approved by the appropriate personnel before the drawdown is made and will be tracked and summarized in a ledger. Anticipated completion date: June 2026 Contact person responsible for corrective action: Harjeet Sidhu, Chief Financial Officer
Title X – Assistance Listing No. 93.217 Recommendation: We recommend management review its patient intake process to ensure income and household size is properly verified, the control is adequately documented and retained in accordance with organizational policies and program requirements. Explanati...
Title X – Assistance Listing No. 93.217 Recommendation: We recommend management review its patient intake process to ensure income and household size is properly verified, the control is adequately documented and retained in accordance with organizational policies and program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: With our recent transition from NextGen to Epic, PPNCS is establishing a new process to ensure patient income and household size are accurately identified and documented in our medical records system. With the enhanced functionalities available in Epic, patients now have the ability to pre-register for appointments via e-Check In. This eliminates reliance on the formerly manual process of patients documenting their income and household size on the registration form (B209) which staff would then enter into the medical records system. In addition, PPNCS will continue to perform internal audits, ensuring that the information provided via e-Check In is accurately reflected in the medical records system. PPNCS’s Standard Operating Procedure will be updated to reflect these changes by July 1, 2026. Name of the contact person responsible for corrective action: Randy Drager, CFO Planned completion date for corrective action plan: July 1, 2026
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