Corrective Action Plans

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Significant Deficiency Finding: 2025-001 Certification of Tenants Criteria and Condition The grant agreement requires ECS to (1) maintain complete tenant files in the San Francisco HMIS ONE System with hard-copy eligibility documents; (2) apply changes to tenant rent portions based on City and Count...
Significant Deficiency Finding: 2025-001 Certification of Tenants Criteria and Condition The grant agreement requires ECS to (1) maintain complete tenant files in the San Francisco HMIS ONE System with hard-copy eligibility documents; (2) apply changes to tenant rent portions based on City and County of San Francisco Department of Homelessness and Supporting Housing (HSH) notifications; and (3) perform required initial, annual, and interim recertifications under the Housing First program model. We noted instances where tenant files did not contain complete eligibility documentation and/or where required recertifications or updates to tenant rent portions were not performed or documented in accordance with the grant requirements. Context ECS provides rental assistance under the program described in Appendix A-2, which requires full documentation of tenant eligibility and strict adherence to rent-portion updates and recertification timelines. Of our 31 selections, we noted 6 instances where homelessness verification was missing, 6 instances where the rent portions based on HSH notifications were incorrect and 10 instances where the recertifications were not completed for the grant period under audit. Questioned Cost There are no questioned costs regarding this finding. Cause The exceptions result from inconsistent file maintenance and monitoring procedures, including insufficient review over documentation completeness and timeliness of recertifications. The issues were centered on tenant files managed by a third-party service provider. Effect Incomplete tenant files and untimely recertifications increase the risk of noncompliance with grant requirements and may result in incorrect tenant rent portions being charged or insufficient support for program eligibility. Repeat Finding This finding is not a repeat finding. Recommendation We recommend that ECS enhance its documentation and monitoring processes with its third-party property managers by implementing a standardized tenant file checklist, conducting periodic supervisory reviews to confirm that all eligibility documents and recertifications are completed and retained, and establishing a tracking process to ensure tenant rent portions are updated promptly based on HSH notifications. View of responsible officials Management agrees with the recommendation. Corrective Action Planned ECS has taken and will continue to take the following steps in the 2026 fiscal year to correct this deficiency. Step 1: Resources ECS began addressing Certificate of Tenancy errors with the hiring an Associate Chief of Real Estate and Asset Management in August, a Director of Property Management in October and a Property Management Compliance Manager in September. Step 2: Best Practices ECS has hired a consulting firm to correct Certificate of Tenancy errors at its one of its sites and will apply the best practices learned to all the affiliate and master lease sites. In addition, ECS has put together policies and procedures and has offered training to both ECS and subcontracted staff on Certificate of Tenancy. ECS will continue to offer compliance training as it takes over property management across all Master Lease sites and the affiliate portfolio. Step 3: Take control of property management Replace outsourced property management with ECS staff to better control Tenant documentation at all master lease and affiliate sites. Step 4: Quality and Compliance ECS has started in a few sites to review Tenant documentation and will expand this review to all sites across its entire portfolio. Implementation Date ECS will fully correct Certificate of Tenancy errors by June 30, 2026. Responsible Personnel The Chief Operating Officer and the Associate Chief of Real Estate and Asset Management.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
Finding 2025-003: Subrecipient Monitoring Condition: The Sponsoring Organization did not consistently perform the required initial on-site review for new subrecipients (centers and FCC providers) within the mandatory 28-day timeframe. View of Responsible Officials: 4C agrees with the audit finding. ...
Finding 2025-003: Subrecipient Monitoring Condition: The Sponsoring Organization did not consistently perform the required initial on-site review for new subrecipients (centers and FCC providers) within the mandatory 28-day timeframe. View of Responsible Officials: 4C agrees with the audit finding. Corrective Action Plan: 4C will implement a new process of requiring the first visit for new providers to be conducted by the 20th of the month with notes required in kidcare system related to scheduling and rescheduling of visit. Responsible Party: Pagie Runion, Strategic Director of Business Services Anticipated Completion Date: June 30, 2026
Finding 2025-002: Subrecipient Monitoring Condition: During the review of internal controls related to subrecipient monitoring, it was noted that the monthly meetings required between the Program Manager and the Monitoring Specialist were not consistently performed throughout the fiscal year. Specif...
Finding 2025-002: Subrecipient Monitoring Condition: During the review of internal controls related to subrecipient monitoring, it was noted that the monthly meetings required between the Program Manager and the Monitoring Specialist were not consistently performed throughout the fiscal year. Specifically, for the 12-month period tested, the required monthly reviews were not documented for 3 out of 12 months. View of Responsible Officials: 4C agrees with the audit finding. Corrective Action Plan: 4C will improve their control process to include a mandatory monthly check with the department manager to verify visits are completed timely. Responsible Party: Pagie Runion, Strategic Director of Business Services Anticipated Completion Date: June 30, 2026
The District is correcting the eligibility status of student participants and is providing training to those that determine the eligibility status to ensure proper eligibility determination in the future.
The District is correcting the eligibility status of student participants and is providing training to those that determine the eligibility status to ensure proper eligibility determination in the future.
2025-002 – Significant Deficiency and Noncompliance – Federal Policies Corrective Action Plan: The City will develop and adopt a comprehensive Uniform Guidance compliance manual that addresses procurement, allowable costs, cash management, subrecipient monitoring, and internal controls. A Federal Co...
2025-002 – Significant Deficiency and Noncompliance – Federal Policies Corrective Action Plan: The City will develop and adopt a comprehensive Uniform Guidance compliance manual that addresses procurement, allowable costs, cash management, subrecipient monitoring, and internal controls. A Federal Compliance Officer will be designated to oversee policy implementation and annual updates. Standard operating procedures will be issued for relevant departments, and mandatory staff training will be conducted. These actions will be completed by March 31, 2026, with ongoing monitoring through quarterly compliance meetings. Anticipated Completion Date: March 31, 2026
REFERENCE: 2025-002 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient ...
REFERENCE: 2025-002 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient services being provided. Corrective Action Plan: Beginning in February 2025, Bailey-Boushay House Administrative staff send out upcoming Eligibility expirations occurring in the next 90 days to the Clinical Supervisor and Director of Outpatient Programs. The Clinical Supervisor forwards a list to each care manager/social worker for clients on their caseload. The Clinical Supervisor discusses the status of these updates during meetings with care manager/social worker. Notes are made on the caseload list to document the discussion of status. The Clinical Supervisor sends a list to the care management team for clients who are within 30 days of their expiration, in order to identify clients who may be out of contact or less engaged in the program. A note is provided with these clients' medications to remind them that they need to complete this eligibility update with a care manager or social worker. Quarterly and monthly emails of eligibility expirations are retained for documentation purposes. Person Responsible: Katie Hara, Director of Outpatient Programs – Bailey Boushay House Completion: February 2025
Name of Responsible Individual: Matt Cooper, Student Financial Services Corrective Action: To strengthen compliance and ensure the accuracy of student aid eligibility determinations, we will enhance Liberty’s quality control (QC) measures within the federal verification process. Our primary goal is ...
Name of Responsible Individual: Matt Cooper, Student Financial Services Corrective Action: To strengthen compliance and ensure the accuracy of student aid eligibility determinations, we will enhance Liberty’s quality control (QC) measures within the federal verification process. Our primary goal is to minimize errors, improve consistency, and ensure all Financial Aid verification activities align with federal regulations and institutional policy. We will begin by implementing a more targeted QC process aimed at validating records of students who submitted subsequent tax documents. We will increase our verification QC selections of this particular population from 35% (current) to 60% (future) to verify data accuracy, documentation completeness, and adherence to ED’s Application and Verification Guide (AVG). Findings from these reviews will be used to identify training needs and process improvements. Staff training will be expanded to focus on federal verification requirements, common error trends, and documentation standards. Refresher trainings will be held with the entire verification processing team, and supplemental individual coaching will be provided on a monthly basis to address any specific issues identified through QC. We will also create reporting to ensure the percentage of reviews mentioned above is maintained by our QC workflow. Regular data analysis will help identify any systemic issues early, allowing for corrective actions to mitigate any compliance issues. By reinforcing staff training, system monitoring, and increased reviews, we will ensure that our federal verification process remains accurate, compliant, and student-centered. Anticipated Completion Date: February 2026
The institution has implemented a new unofficial withdrawals (UW) policy. This policy defines an unofficial withdrawal as a student who stops attending one or more courses without officially withdrawing. An unofficial withdrawal will be assigned to any student who has consecutively ceased attending ...
The institution has implemented a new unofficial withdrawals (UW) policy. This policy defines an unofficial withdrawal as a student who stops attending one or more courses without officially withdrawing. An unofficial withdrawal will be assigned to any student who has consecutively ceased attending a course for three weeks and for whom no evidence of attendance is available at the time of reporting within the specified period. If a student stops attending all their courses, Registrar's Office will inactivate the student and issue a report to the Financial Aid office for an R2T4 calculation. This process will occur on the last instructional day before the final exams, as outlined in the academic calendar. According to the policy, Faculty members submit a report of students who have stopped attending (using an official form) and indicate the last date of academic activity for each student reported as UW. These students are not assigned a grade but rather a "UW." Students who complete the course by continuing to attend but fail to meet the academic requirements receive a grade of "F." In addition, effective March 2025, the Academic Deanship has established an institutional policy for submitting grade records (roll books) at the end of each academic term. Since 2024, some faculty members have participated in a pilot project to adopt the Electronic Gradebook (Rollbook). After adjusting the system, the institution will offer training sessions to all faculty members. By the end of the February-May 2025 term,faculty will submit the required documentation to maintain records of the grades assigned to each student.
FINDING 2025-002 Finding Subject: Child Nutrition Cluster-Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Missy Schultheis Contact Phone Number and Email Address: 812-354-8478 mschultheis@pcsc.k12.in.us Views of Responsible Officials: We concur with the fin...
FINDING 2025-002 Finding Subject: Child Nutrition Cluster-Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Missy Schultheis Contact Phone Number and Email Address: 812-354-8478 mschultheis@pcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School Corporation will review and update the existing procurement policy to ensure it clearly outlines the procedures for different purchasing methods including the specific thresholds. We will establish a procedure requiring the retention of all documentation supporting procurement decisions. We will develop a process to verify that vendors/contractors are not suspended or debarred by any federal or state agency prior to entering into a "covered transaction" or contract. Anticipated Completion Date: This be implemented in the 2025-2026 school year and will continue for future years.
The District will be utilizing the consulting service with Julian & Grube in the future.
The District will be utilizing the consulting service with Julian & Grube in the future.
Audit Recommendation a) 2025-004: Full Service Community Schools-Assistance Listing No. 84.215J Grant NO. - S215J220016 Grant Period-Year ended June 30, 2025 the auditors recommend the District to implement a process that ensures an understanding of the grant revenue and expenditure recognition proc...
Audit Recommendation a) 2025-004: Full Service Community Schools-Assistance Listing No. 84.215J Grant NO. - S215J220016 Grant Period-Year ended June 30, 2025 the auditors recommend the District to implement a process that ensures an understanding of the grant revenue and expenditure recognition process. Regular reconciliations should be performed and monitored against the grant finance reports. Expenditures should be monitored against the approved budgets and overspent grants. Corrective Action Plan a) 2025-004: The District plans to ensure in-depth training on all grants the District receives and require regular reconciliations to the general ledger by using our financial program as well a spreadsheet at the end of every month and institute more oversight over the grant process. Implementation Date - June 30, 2026 Person Responsible for Implementation - Colleen Bellinger, School Business Manager
DATE: December 9, 2025 SUBJECT: Corrective Action Plan for Finding 2025-001 – Control Deficiency in Internal Controls over Compliance and Instance of Noncompliance. Management agrees with the auditor recommendation. During the first and second quarters of fiscal year 2024-25, the City underwent pers...
DATE: December 9, 2025 SUBJECT: Corrective Action Plan for Finding 2025-001 – Control Deficiency in Internal Controls over Compliance and Instance of Noncompliance. Management agrees with the auditor recommendation. During the first and second quarters of fiscal year 2024-25, the City underwent personnel changes in the Affordable Housing Division, specifically with the key role of CDBG Program Coordinator. The transition created temporary gaps in institutional knowledge and disrupted workflow continuity. This caused the City to miss submissions of Federal Funding Accountability and Transparency Act (FFATA) reports. Upon discovery that the FFATA reports had been delayed, the new CDBG Program Coordinator entered the agreements into the federal reporting system to bring reporting up to date. Responsible Party: Community Development Program Coordinator Completion Date: October 6, 2025 Effective October 6, 2025, all future subrecipient agreements will be reported to SAM.gov in a timely manner by the Community Development Program Coordinator (or another coordinator as applicable). Subrecipient Awardee Checklists have been updated to ensure this step is included as part of the awarding process, which are reviewed by the Grant Program Coordinator or designee.
2025-001 Recertifications 14.881 Moving to Work Demonstration Program – Award No. OCD26401344019MTW Responsible Official Sarah Scott Director of Leased Housing Plan Detail There has been a greater focus on ensuring new past dues (recertifications not completed on time) do not occur while we continue...
2025-001 Recertifications 14.881 Moving to Work Demonstration Program – Award No. OCD26401344019MTW Responsible Official Sarah Scott Director of Leased Housing Plan Detail There has been a greater focus on ensuring new past dues (recertifications not completed on time) do not occur while we continue to resolve older ones. Starting with April 1, 2024 regular recertifications, we implemented a more rigorous monitoring process. The day after data entry for each recertification is due, the Director of Leased Housing generates a comprehensive report that consolidates information from multiple sources, including our software and internal tracking systems. Once verified, the Director provides these reports—including past-due recertifications from prior months—to managers for follow-up. Managers are responsible for ensuring the timely resolution of all cases on the report. Managers are held accountable for ensuring past-due cases do not reappear in subsequent months. Since the implementation of this process, we have seen a significant reduction in the number of past-due recertifications for assigned caseloads as management is proactive in ensuring no name, especially those on vacant caseloads due to numerous staff medical leaves, reaches that list. Additionally, as of October 2025, the Leased Housing Department will be operating within our new Yardi software system, a significant upgrade designed to enhance efficiency, accuracy, and user experience across all aspects of program administration. Yardi enables considerably faster processing times compared to our current platform, reducing the time needed to complete certifications, adjustments, and case updates. One of the most beneficial features of Yardi is its Recertification Dashboard, which provides staff with real-time visibility into upcoming deadlines, pending tasks, and the overall status of each case. The dashboard includes automated prompts and workflow reminders throughout the recertification process, ensuring staff stay on track and that each step is completed in sequence. In addition to speed and organization, Yardi offers enhanced data accuracy and integration capabilities, minimizing duplication and manual entry errors. These improvements will help staff manage their caseloads more effectively, provide more timely service to participants and property owners, and ensure compliance with program requirements. Anticipated Completion Date June 30, 2026 – Past due percentages will be lowered to acceptable levels with those outstanding being a result of the hearings and appeals process.
Comments on the Finding and Each Recommendation: The Corporation did not make the total required reserve for replacement deposits during the year ended June 30, 2025, which resulted in the reserve for replacements account being underfunded by $1,205 as of June 30, 2025. The management agent should t...
Comments on the Finding and Each Recommendation: The Corporation did not make the total required reserve for replacement deposits during the year ended June 30, 2025, which resulted in the reserve for replacements account being underfunded by $1,205 as of June 30, 2025. The management agent should transfer funds of $1,205 from the operating account in order to bring the reserve for replacements account current. Action(s) taken or planned on the finding Management agrees with the recommendation. Management transferred $1,205 from the operating account to the reserve for replacements account on August 26, 2025. No further action is required.
Comments on the Finding and Each Recommendation: The Corporation's Flexible Subsidy Loan was due in full upon maturity of the Corporation's Section 202 mortgage loan, which occurred in March 2017. As of June 30, 2025, the Flexible Subsidy Loan has not been repaid and the Corporation is in technical ...
Comments on the Finding and Each Recommendation: The Corporation's Flexible Subsidy Loan was due in full upon maturity of the Corporation's Section 202 mortgage loan, which occurred in March 2017. As of June 30, 2025, the Flexible Subsidy Loan has not been repaid and the Corporation is in technical default on the Flexible Subsidy Loan. Management should continue communicating with HUD in order to obtain approval for the deferment request for the Section 201 Flexible Subsidy Loan. Action(s) taken or planned on the finding Management agrees with the recommendation. Management has submitted a request for deferment of the Flexible Subsidy Loan. Management is awaiting HUD approval of the deferment request.
Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: RAED will develop a set of procedures the will allow them to be in compliance for subrecipient monitoring. Official Responsible for Ensuring CAP: Savannah Walsh, E...
Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: RAED will develop a set of procedures the will allow them to be in compliance for subrecipient monitoring. Official Responsible for Ensuring CAP: Savannah Walsh, Executive Director, is the official responsible for ensuring corrective action. Planned Completion Date for CAP: June 30, 2026 Plan to Monitor Completion of CAP: The Board of Education will be monitoring this corrective action plan. Savannah Walsh Executive Director
Condition: The School District relies on two-third party vendors to manage key financial aid systems, including student information, eligibility determinations, disbursement calculations, and reporting. During the audit period, the institution did not perform any oversight activities or testing to v...
Condition: The School District relies on two-third party vendors to manage key financial aid systems, including student information, eligibility determinations, disbursement calculations, and reporting. During the audit period, the institution did not perform any oversight activities or testing to verify the integrity, accuracy, or compliance of the systems managed by the vendor. There were no documented controls, service-level agreements, or monitoring procedures in place. Planned Corrective Action: The School District will establish formal oversight procedures for all third-party vendors supporting financial aid functions. This will include developing and maintaining service-level agreements, implementing documented monitoring and testing protocols, and conducting periodic reviews to verify system accuracy, data integrity, and federal compliance. Staff will be trained on these updated processes to ensure ongoing accountability. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: June 30, 2026
Condition: The institution does not have a process or controls in place for a timely review of program eligibility, ECAR. Planned Corrective Action: The School District will establish a formal process to ensure timely and documented reviews of program eligibility in accordance with federal requireme...
Condition: The institution does not have a process or controls in place for a timely review of program eligibility, ECAR. Planned Corrective Action: The School District will establish a formal process to ensure timely and documented reviews of program eligibility in accordance with federal requirements. Staff will be trained on the new procedures, and the School District will implement internal controls to monitor program eligibility on a regular schedule. These steps will help ensure ongoing compliance and accurate determinations moving forward. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: June 30, 2026
Condition: The institution did not reimburse students with credit balances within 14 days of the balance being posted to their student ledger. Planned Corrective Action: The School District will strengthen its procedures to ensure all student credit balances are identified and refunded within the re...
Condition: The institution did not reimburse students with credit balances within 14 days of the balance being posted to their student ledger. Planned Corrective Action: The School District will strengthen its procedures to ensure all student credit balances are identified and refunded within the required 14-day timeframe. Staff will receive training on the updated process, and the District will implement regular monitoring to verify timely issuance of refunds going forward. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: June 30, 2026
Finding 2025-001 – Significant Deficiency over Internal Controls related to Debarment Compliance – ARA – 21.027 Recommendation: Habitat should have the required certifications completed annually to ensure compliance with regulations and adherence to internal policies. Corrective Action: We have alre...
Finding 2025-001 – Significant Deficiency over Internal Controls related to Debarment Compliance – ARA – 21.027 Recommendation: Habitat should have the required certifications completed annually to ensure compliance with regulations and adherence to internal policies. Corrective Action: We have already implemented procedures to ensure the certifications are signed. Commencing in October 2024 we began taking steps to implement our corrective action plan. In 2025 we performed internal audits to ensure compliance and significant effort has been made to ensure the proper documentation is obtained and retained. Going forward we will continue to educate and train those involved with these processes and perform internal audits to ensure processes are functioning as designed. Personnel Responsible for Corrective Action: Shelly Dillow, SVP of Accounting and Finance and Paul Harvey, SVP of Construction Anticipated Completion Date for Corrective Action: The Corrective Action has already been implemented as of the date of this report. If there are questions regarding this corrective action plan, please call Shelly Dillow, SVP of Accounting and Finance, at (615) 942-1264. Sincerely, Habitat for Humanity of Greater Nashville Shelly Dillow, SVP of Accounting and Finance Paul Harvey, SVP of Construction
Allowable Costs - Special Education Cluster (IDEA) (Significant Deficiency - Other Matter) Description of Finding 1 employee’s pay rate was not updated to reflect the new fiscal year 2025 collective bargaining agreement for their specific union after its implementation in December 2024. Although ret...
Allowable Costs - Special Education Cluster (IDEA) (Significant Deficiency - Other Matter) Description of Finding 1 employee’s pay rate was not updated to reflect the new fiscal year 2025 collective bargaining agreement for their specific union after its implementation in December 2024. Although retroactive pay for hours worked prior to ratification was correctly calculated and paid, the payroll system continued using the prior contract’s rate for all subsequent pay periods through the end of the school year. This occurred due to a failure in the payroll update process following contract implementation. Statement of Concurrence or Nonconcurrence Management agrees with the finding. Corrective Action The Board of Education will implement additional controls over payroll updates and establish a documented process for updating pay rates immediately after contract ratification. Additionally, review and verification of rate changes, along with periodic reconciliation against approved salary schedules or union agreements, should be performed to ensure accuracy and compliance. Name of Contact Person Christian Strickland, BOE Chief Operating Officer Projected Completion Date June 30, 2025
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