Corrective Action Plans

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Management is working to obtain the overdue reports.
Management is working to obtain the overdue reports.
Management did not have documented controls in place to ensure contractors are not suspended or debarred from participating in federally funded activity Planned Corrective Action: To strengthen compliance documentation and ensure consistent audit support, VOAC has implemented the following correctiv...
Management did not have documented controls in place to ensure contractors are not suspended or debarred from participating in federally funded activity Planned Corrective Action: To strengthen compliance documentation and ensure consistent audit support, VOAC has implemented the following corrective actions: 1.Policy Enhancement: The procurement procedure has been updated to explicitly require saving and retaining a time-stamped screenshot or PDF confirmation of each SAM.gov verification showing the verification date and results. Where applicable, contractors subject to 2 CFR 200.214 must also provide a self-certification statement within the executed agreement. 2.Centralized Recordkeeping: Verification evidence will be maintained in both the individual contract file and the centralized grant management system. 3.Annual Training and Refresher: Procurement and grants management staff will participate in annual training to reinforce 2 CFR 200.214 requirements and best practices for documentation and record retention. Contact person responsible for corrective action: Ian Kile, Director of Internal Control, and Chiyoko Yokota, Chief Financial Officer Anticipated Completion Date: 2/28/26
Pacific House and Subsidiaries has transitioned to a new CPA firm and is working closely with them to ensure the Data Collection Form is timely submitted for the fiscal year ended June 30, 2025 and in future.
Pacific House and Subsidiaries has transitioned to a new CPA firm and is working closely with them to ensure the Data Collection Form is timely submitted for the fiscal year ended June 30, 2025 and in future.
Finding Number: 2025-002 Anticipated Completion Date: 10/07/2025 Responsible Contact Person: Katherine Miranda, University Registrar Kelly Burt, Assistant Registrar Records Management and Reporting Michele Bergman, Assistant Registrar, Records Management and Reporting Planned Corrective Action: The ...
Finding Number: 2025-002 Anticipated Completion Date: 10/07/2025 Responsible Contact Person: Katherine Miranda, University Registrar Kelly Burt, Assistant Registrar Records Management and Reporting Michele Bergman, Assistant Registrar, Records Management and Reporting Planned Corrective Action: The Offices of the Registrar and Admission Operations reviewed the case, reviewed the proper student record protocol, and added a reporting checkpoint to review for dually enrolled students before submitting enrollment reports to the National Student Clearinghouse (NSC). Once NSLDS is updated with NSC data, the Office of the Registrar will work with Office of Financial Aid to confirm NSLDS is accurate for the dually enrolled students.
Finding Number: 2025-001 Completion Date: 03/31/2025 Responsible Contact Person: Kami Greene, Director of Accounting and Controller Kristen Cope, Assistant Controller Corrective Action: The University enhanced its written procedures for requesting cash draws and further trained new staff on policies...
Finding Number: 2025-001 Completion Date: 03/31/2025 Responsible Contact Person: Kami Greene, Director of Accounting and Controller Kristen Cope, Assistant Controller Corrective Action: The University enhanced its written procedures for requesting cash draws and further trained new staff on policies and procedures to ensure compliance. In addition, a review process has been established before each cash draw takes place to ensure that all cash draws are for expenses that were incurred to prevent funds from being overdrawn.
Finding Reference: 2025-001 Description of Finding: HUD regulations require certifications to be completed and entered timely to ensure accurate calculation of Housing Assistance Payments (HAP), Total Tenant Payment (TTP) and utility reimbursements. Per 24 CFR section 982.516, the Authority must ree...
Finding Reference: 2025-001 Description of Finding: HUD regulations require certifications to be completed and entered timely to ensure accurate calculation of Housing Assistance Payments (HAP), Total Tenant Payment (TTP) and utility reimbursements. Per 24 CFR section 982.516, the Authority must reexamine family income and composition at least once every two years and adjust the tenant rent and housing assistance payment as necessary using the documentation from third party verification. Of the 60 Moving to Work files tested, the following items were noted: • 40 instances of certifications not completed timely • 6 instances where the file did not contain income support • 3 instances where housing quality standards inspections were not completed within the last 2 years • 1 instance in which a rent comparison was not completed for a new move in Statement of Concurrence or Nonconcurrence: Louisville Metro Housing Authority agrees with Cherry Bekaert in reference to audit finding 2025-001. Corrective Action: LMHA continues to work through issues around the proper and timely processing of program certifications to support accurate Housing Assistance Payments, Total Tenant Payments and utility reimbursements. Currently, recertifications are processed on a biennial basis schedule, through a three-tiered system outlined in our updated MTW plan. This will address timeliness of recertification while also ensuring compliance and review of supporting documentation. Please note the following rules tied to LMHA’s three-tiered recertification system: 1) When the family is zero income, they will go to an annual recertification. 2) When family is working, (enrolling in KTAP (Kentucky Transitional Assistance Program), receiving Child Support, and other similar sources of income) they will go to a biennial recertification. 3) When a family has fixed income, (receiving Social Security, Supplemental Security Income, and/or Pension payments), they will go to a triennial recertification. The HCV Team is also working with Yardi (ERP system) to maximize the reporting and monitoring of the recertification schedule. The manager initiates the tracking for needed processing and possible termination of participants. With the three-tiered system, staff will be able to review all tenant information closely during recertifications to ensure proper housing assistance payments. Additionally, to improve sufficient controls and internal monitoring, the HCV Team is partnering with the Compliance Team to review tenant files for errors and improper supporting documentation.
Finding 2025.001 - Procurement, Suspension and Debarment Recommendation The Center should develop a written procedure to review all vendors and individuals in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff ...
Finding 2025.001 - Procurement, Suspension and Debarment Recommendation The Center should develop a written procedure to review all vendors and individuals in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compliance with the requirement. Repeat Finding No Action Taken To establish, implement, and maintain a standardized screening process that ensures no federal funds are paid to excluded or debarred individuals or vendors, with documented evidence and ongoing monitoring, HealthFirst has developed written policies and procedures, outlining assigned responsibilities, screening frequencies, and documentation & retention. Staff training to correct inaccurate searches have been provided. If there are any question regarding this plan, please e-mail Lisa Jones at ljones@healthfirstfr.org. Sincerely, Lisa Jones Chief Executive Offi
Criteria or Specific Requirement: Subparts D and E of 2 CFR Part 200 require a nonfederal entity to establish written policies, procedures, and standards of conduct, including procedures to implement the cash management requirements of 2 CFR section 200.305, procedures that comply with the procureme...
Criteria or Specific Requirement: Subparts D and E of 2 CFR Part 200 require a nonfederal entity to establish written policies, procedures, and standards of conduct, including procedures to implement the cash management requirements of 2 CFR section 200.305, procedures that comply with the procurement standards of 2 CFR sections 200.318 through 200.326, and procedures for determining the allowability of costs in accordance with Subpart E of 2 CFR Part 200. Specifically, 2 CFR sections 200.430, 200.431, and 200.475 require written policies concerning compensation for personal services, fringe benefits, and travel costs, respectively. Views from Responsible Officials: Management agrees with the finding. Management has established written policies and procedures after yearend that were the policies and procedures followed during the year under audit and meets the requirements of Subparts D and E of 2 CFR Part 200. Contact Person: John Jacques Date of Completion: November 14, 2025
Criteria or Specific Requirement: Nonfederal entities other than states, including those operating federal programs as subrecipients of states, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which re...
Criteria or Specific Requirement: Nonfederal entities other than states, including those operating federal programs as subrecipients of states, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR Part 200. Views from Responsible Officials: Management agrees with the finding. Management has established written policies and procedures for procurement. Management confirmed policies and procedures were followed and monitored during the construction of the project. Written policies and procedures were completed after year-end. Contact Person: John Jacques Date of Completion: November 14, 2025
Finding 2025.001 - Procurement, Suspension and Debarment Recommendation The Organization should develop a written procedure to review all vendors and individuals in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate ...
Finding 2025.001 - Procurement, Suspension and Debarment Recommendation The Organization should develop a written procedure to review all vendors and individuals in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compliance with the requirement. Repeat Finding No Action Taken Business Office will verify compliance for all new vendors and conduct annual compliance review of existing vendors. Human Resources will verify compliance for all new hires and conduct annual compliance review of existing employees.
Finding 2025-002: Reporting (Material Weakness, repeat finding) U.S. Treasury Department – COVID-19 Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027) Statement of Condition: During testing one of the College’s quarterly ARPA expenditure reports was submitted to Bucks County after the de...
Finding 2025-002: Reporting (Material Weakness, repeat finding) U.S. Treasury Department – COVID-19 Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027) Statement of Condition: During testing one of the College’s quarterly ARPA expenditure reports was submitted to Bucks County after the deadline per the grant agreements. The report tested was submitted 20 days late. Criteria: The College is a subrecipient of ARPA funding from Bucks County. The grant agreements state the College must submit quarterly expenditure reports to the County 11 days after the end of the quarter (calendar year). Cause: The College did not have adequate controls in place to ensure the timely filing of expenditure reports. Effect: Failure to comply with ARPA reporting requirements could jeopardize future federal funding. Recommendation: We recommend that the College reconcile, review, and submit reports in a timely manner based on grant agreements. Questioned Costs: This finding does not result in questioned costs. View of responsible officials and planned corrective actions: Management agrees with the finding. The College has strengthened the process to ensure the timely and accurate reconciliation, review, and submission of expenditure reports consistent with the requirements of all grant agreements. The College’s Grant Office has created a Grant Project Management Platform to track compliance requirements for all grants including timely invoicing and reporting. This platform provides a dashboard and reminder functions for deadline monitoring. The Grants Manager participates in weekly meetings with the Executive Director, Research, Assessment, Data Analytics, & Reporting, to review deadlines and facilitate the timely and accurate completion of all tasks related to grant compliance. Name(s) of Contact Person(s) Responsible for Corrective Action: Elana Felberg, Grants Manager Anticipated Completion Date: January 31, 2026
Views of Responsible Officials and Planned Corrective Actions - The University’s Office of Student Financial Services agrees with the recommendation and will ensure that Return of Title IV (R2T4) calculations and applicable returns of funds for all students who officially or unofficially withdraw ar...
Views of Responsible Officials and Planned Corrective Actions - The University’s Office of Student Financial Services agrees with the recommendation and will ensure that Return of Title IV (R2T4) calculations and applicable returns of funds for all students who officially or unofficially withdraw are completed within required regulatory time frames. To strengthen internal controls related to R2T4 processing, the Office of Student Financial Services under the direction of the Director of Student Financial Services has taken and will continue the following actions: • Reinforce and update R2T4 procedures to clearly document regulatory timelines, roles, and responsibilities, and to include defined ongoing monitoring practices. These updated procedures incorporate periodic review of R2T4 activity to ensure continued compliance. • Enhance the existing internal tracking mechanism to support timely completion of R2T4 calculations and fund returns. This enhancement includes the ability to generate reports that identify upcoming deadlines, completed actions, and any items requiring follow-up. • Provide refresher training to staff within the Office of Student Financial Services and partner offices involved in R2T4 processing, with emphasis on compliance requirements, timelines, documentation standards, and shared accountability across offices. • Incorporate a secondary review process as part of the existing R2T4 procedure. A designated secondary reviewer within the Office of Student Financial Services will confirm the accuracy and timeliness of each R2T4 calculation and associated fund return, with completion of the review documented within the tracking system. These corrective actions will be implemented upon review and approval and will be effective beginning Spring 2026.
CFDA 10.565 Commodity Supplemental Food Program Name of Contact Person: Shelly Neeley, Program Specialist Corrective Action: Eligibility requirements regarding the Commodity Supplemental Food program (CSFP) are recognized by West Ohio Food Bank (WOFB) and WOFB continues making internal controls a to...
CFDA 10.565 Commodity Supplemental Food Program Name of Contact Person: Shelly Neeley, Program Specialist Corrective Action: Eligibility requirements regarding the Commodity Supplemental Food program (CSFP) are recognized by West Ohio Food Bank (WOFB) and WOFB continues making internal controls a top priority in the program’s operation. There are currently 1,800 applications processed through WOFB and 43 site locations for CSFP. These include those applicants on the active list and the wait list as well as those who may not qualify for the program. During the auditing process, there were 11 participants that did not have a current/updated application on file yet received a distribution. To ensure that all applications are renewed within a twelve-month period, and that the recipients without a valid application on file do not receive distributions until a valid, up-to-date application has been obtained, WOFB has begun to implement and will continue implementing the following internal control procedures. WOFB will continue to update/renew all applications each March to have all expiration dates within the same month each year. The master spreadsheet has also been updated to include parameters that will flag an upcoming expiration date. This will assist the senior sites in knowing more timely who needs a renewal application at their location. In addition, Pantry Trak/Fresh Trak is being updated and revised. I have been working closely with Mid-Ohio in revising the CSFP portion to better meet the needs of the program at WOFB. The ultimate goal is to use the Pantry Trak system to log and track all CSFP information electronically. This too will increase the accuracy of the data. As an additional audit of accuracy WOFB will conduct an internal audit monthly by randomly pulling a sampling of 3 percent (48) of the 1,600 CSFP recipients to verify the accuracy of the applications on file. Proposed Completion Date: The processes implemented will be ongoing. As the Pantry Trak program tool continues to improve its use for tracking and logging, use for CSFP will increase.
Monitoring over federal awards – The District has corrected the reporting error for ESSER fund expenditures and is increasing its monitoring responsibilities to meet the needs of federal programs in the future. The District will be developing controls over reporting of federal funds to ensure these ...
Monitoring over federal awards – The District has corrected the reporting error for ESSER fund expenditures and is increasing its monitoring responsibilities to meet the needs of federal programs in the future. The District will be developing controls over reporting of federal funds to ensure these funds reconcile to the general ledger going forward.
Reporting - Federal Awards and Expenditures - ESSER – The District has corrected the reporting error for ESSER fund expenditures and is increasing its monitoring responsibilities to meet the needs of federal programs in the future. The District will be developing controls over reporting of federal f...
Reporting - Federal Awards and Expenditures - ESSER – The District has corrected the reporting error for ESSER fund expenditures and is increasing its monitoring responsibilities to meet the needs of federal programs in the future. The District will be developing controls over reporting of federal funds to ensure these funds reconcile to the general ledger going forward.
Contact Person David Drapeaux Corrective Action Plan This finding was resolved in FY2025 through a joint agreement between the District and NDDPI. The questioned costs of $86,171, that were discovered during a separate NDDPI monitoring process, were all returned to the state before the beginning of ...
Contact Person David Drapeaux Corrective Action Plan This finding was resolved in FY2025 through a joint agreement between the District and NDDPI. The questioned costs of $86,171, that were discovered during a separate NDDPI monitoring process, were all returned to the state before the beginning of the 2025 audit. This issue is resolved. Completion Date 05/08/25
Enrollment information was not submitted within the required timeframe by the College. Personnel Responsible for Corrective Action: Dena Norris, Associate Vice Chancellor of Student Financial Services, and Tara Dettmer, Director of Financial Aid – Fiscal Operations Anticipated Completion Date: Corre...
Enrollment information was not submitted within the required timeframe by the College. Personnel Responsible for Corrective Action: Dena Norris, Associate Vice Chancellor of Student Financial Services, and Tara Dettmer, Director of Financial Aid – Fiscal Operations Anticipated Completion Date: Corrective action plan will be implemented by June 30, 2026. Views of Responsible Officials and Planned Corrective Action Plan: Despite best efforts by the College to correct the errors in enrollment reporting, the College experienced turnover among staff, and as a result, was unable to shift staffing resources or quickly hire replacement staff to correct the finding. Metropolitan Community College (MCC) is in the process of hiring additional staff dedicated to enrollment and compliance reporting. MCC will make a random selection of 10-15 students each month to verify data was correctly transmitted to National Student Clearinghouse (NSC). A secondary check of these students will be done to ensure the data is also transmitted to the National Student Loan Data System (NSLDS). MCC will also ensure error reports and other data issues are resolved in a timely manner to ensure reporting of students is completed within the regulatory timeframe. Due to the implementation of a new Enterprise Resource Planning system MCC is also validating and correcting any submission errors.
Condition: The Commission did not submit the required financial and performance reports promptly. Planned Corrective Action: The Capital Team Project Manager continues to reconcile HUD’s EPIC and ELOCC systems with Yardi monthly to ensure timely filing of capital projects' closeouts. This tracking c...
Condition: The Commission did not submit the required financial and performance reports promptly. Planned Corrective Action: The Capital Team Project Manager continues to reconcile HUD’s EPIC and ELOCC systems with Yardi monthly to ensure timely filing of capital projects' closeouts. This tracking critical spreadsheet, created by the Lead Performance Officer, will trigger key reporting dates for the DHC Capital Fund Program to remain in compliance with HUD reporting deadlines. At a minimum, monthly, this critical spreadsheet is distributed to the Supervisor of Capital and the Lead Performance Officer to ensure compliance. However, this was on the radar and continues the process of cleaning older items for corporate hygiene. As of December 2025, this was closed out and approved in EPIC by HUD. Contact person responsible for corrective action: Michael Edwards, Capital Asset & Skilled Trades Supervisor Anticipated Completion Date: 12/31/2025
Condition: The Commission did not complete fiscal year 2025 recertifications. Planned Corrective Action: Staff have been retrained on the compliance requirements under the standards of the HCV Program through the oversight of the Rental Assistance Department Manager and Continued Occupancy Superviso...
Condition: The Commission did not complete fiscal year 2025 recertifications. Planned Corrective Action: Staff have been retrained on the compliance requirements under the standards of the HCV Program through the oversight of the Rental Assistance Department Manager and Continued Occupancy Supervisor. The Department Manager and Supervisor continue to utilize all Yardi monitoring reports to ensure the Department is operating in accordance with industry standards. Reporting is be done and monitored monthly to meet set goals. Weekly, Department Manager has review the certification pipeline to ensure compliance and follow up with the Housing Specialist to ensure compliance and meeting set weekly and monthly goals and metrics. We continue to work in accordance with HUD rules and regulations where Annual Recertification processes are concerned. Per HUD communication provided to us, as of June 30, 2025, HCV is 100% compliant with HUD recertification requirements. Contact person responsible for corrective action: Felicia Burris, HCV Program Manager Anticipated Completion Date: 7/1/2025
Condition: The Commission was unable to send failed HQS inspection notices promptly to participants who needed to correct deficiencies. Planned Corrective Action: HCV will hire additional internal support for HQS inspections to work alongside external vendors and ensure timely updates/mailings/, and...
Condition: The Commission was unable to send failed HQS inspection notices promptly to participants who needed to correct deficiencies. Planned Corrective Action: HCV will hire additional internal support for HQS inspections to work alongside external vendors and ensure timely updates/mailings/, and closeouts are uploaded to the work management system, Yardi. Contact person responsible for corrective action: Felicia Burris, HCV Program Manager Anticipated Completion Date: 6/30/2026
The purpose of the Goods Receipt (GR) is to record receipt of goods or services as soon as they are delivered and verified to be in acceptable condition. A Goods receipt must be posted in SAP for all items actually received. Vendors submit invoice(s) referencing the purchase order (PO) directly to A...
The purpose of the Goods Receipt (GR) is to record receipt of goods or services as soon as they are delivered and verified to be in acceptable condition. A Goods receipt must be posted in SAP for all items actually received. Vendors submit invoice(s) referencing the purchase order (PO) directly to Accounts Payable after delivery, indicating that the goods or services have been provided and requesting payment. Accounts Payable then reviews the vendor invoice, purchase order, and goods receipt in SAP to perform the required three-way match (PO, GR, and vendor invoice) before processing payment. 1. The Accounts Payable team will collaborate with the Procurement Services Division to establish and implement a process that ensures the timely review and reconciliation of Goods Receipt (GR) entries. This will include the development of clear guidance / training materials for schools and offices to periodically review their GR balances. Training will be conducted via Virtual Office Hours on a quarterly basis for sites to make necessary adjustments when the goods or services received differ from the original Purchase Order (PO) or the corresponding invoice. 2. The Accounts Payable team will collaborate with the Procurement Services Division to develop supplemental documentation and guidance regarding proof of delivery for goods and services received. 3. Accounts Payable staff will receive ongoing training throughout the year on documentation and reconciliation requirements, particularly when new internal controls, procedures, and processes are created. Training will be incorporated into regular team meetings, procedural updates, and onboarding for new team members to maintain alignment and accuracy across the department. The implementation target date for the above corrective action plan is June 30, 2026. Name: Rocio Saucedo Title: Director of Accounts Payable Contact Information: Rocio.Saucedo@lausd.net
Condition: Nine (9) employee payroll expenditures were claimed at an hourly rate greater than that approved by ISBE. Corrective Action Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. In addition, budgets will be mo...
Condition: Nine (9) employee payroll expenditures were claimed at an hourly rate greater than that approved by ISBE. Corrective Action Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. In addition, budgets will be monitored and amended accordingly within the period performance of the grant. Responsible Person: Janiesa Owens, Chief School Business Official Anticipated Completion Date: June 30, 2026
Finding #2025-001: During the year ended September 30, 2025, the Corporation did not make the HUD required number of deposits to the reserve for replacements. Recommendation: Management should transfer $5,119 from the operating account to the reserve for replacements account when there is cash avail...
Finding #2025-001: During the year ended September 30, 2025, the Corporation did not make the HUD required number of deposits to the reserve for replacements. Recommendation: Management should transfer $5,119 from the operating account to the reserve for replacements account when there is cash available. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. Management deposited $5,119 into the replacement reserve on November 18, 2025, and will continue to make monthly deposits to the reserve as cash flow allows to ensure compliance.
Finding #2025-001: During the year ended September 30, 2025, the Corporation did not make the HUD required number of deposits to the reserve for replacements. Recommendation: Management should transfer $3,535 from the operating account to the reserve for replacements account when there is cash avail...
Finding #2025-001: During the year ended September 30, 2025, the Corporation did not make the HUD required number of deposits to the reserve for replacements. Recommendation: Management should transfer $3,535 from the operating account to the reserve for replacements account when there is cash available. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. Management deposited $3,535 into the replacement reserve on November 7, 2025, and will continue to make monthly deposits to the reserve as cash flow allows to ensure compliance.
The Food Service Director has implemented a corrective plan focused on (1) re-training on production record requirements, (2) real-time verification and monitoring, (3) escalation for noncompliance, and (4) sustained oversight until compliance is consistent. The District will maintain documentation ...
The Food Service Director has implemented a corrective plan focused on (1) re-training on production record requirements, (2) real-time verification and monitoring, (3) escalation for noncompliance, and (4) sustained oversight until compliance is consistent. The District will maintain documentation of monitoring and follow-up to demonstrate that corrective actions are in place and effective. Implementation: December 1, 2025
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