Corrective Action Plans

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Federal and State Financial Assistance Programs Year Ended May 31, 2025 CORRECTIVE ACTION PLAN Audit Finding Reference: 2025-001 Planned Corrective Action: The University conducted a full review of the population of cancellations for the fiscal year ending May 31, 2025, comprising of 53 students. Th...
Federal and State Financial Assistance Programs Year Ended May 31, 2025 CORRECTIVE ACTION PLAN Audit Finding Reference: 2025-001 Planned Corrective Action: The University conducted a full review of the population of cancellations for the fiscal year ending May 31, 2025, comprising of 53 students. The review identified seven instances of late reporting, all of which were previously corrected through the University’s monthly disbursement reconciliation processes, but beyond the 15 calendar day reporting requirement. Each of the identified instances resulted from a system defect which caused canceled BBAY Direct Loans reduced to zero (“0”) to receive an automatic null attendance cost. Due to the automatic null value, the record was excluded from the financial aid management system to COD record extraction process. The University has created a report to identify instances where the attendance cost value is null. When identified, action will be taken to populate the attendance cost to zero and allow extraction. The records will be subsequently verified to confirm extraction for submission to COD and reports will be reviewed weekly by the supervisor. The University will continue to review and implement additional controls to ensure disbursement records are submitted to COD within 15 calendar days. To ensure enhanced oversight and monitoring controls are effective to maintain compliance and timely reporting to COD, management will incorporate this review into their routine Assurance validation processes for students from the identified population. These remediation efforts and risk management strategies will continue to be reviewed and implemented throughout fiscal year 2026. The University continues to update controls as needed to ensure compliance with an estimated completion date of May 31, 2026. Contact Person: Suzanne Weems Controller Baylor University Phone: (254) 710-3731
Condition: We noted no indication that certified payrolls were obtained and reviewed by Township officials prior to payment being made to a contractor for construction work performed in one instance. Planned Corrective Action: While controls are in place to ensure payments to vendors are not made wi...
Condition: We noted no indication that certified payrolls were obtained and reviewed by Township officials prior to payment being made to a contractor for construction work performed in one instance. Planned Corrective Action: While controls are in place to ensure payments to vendors are not made without completed review of certified payrolls, staff acknowledges records kept did not provide adequate backup to verify these controls. Going forward, staff will not only be sure to keep copies of certified payrolls with related invoices, they will also maintain records that confirm invoices without certified payrolls did not include labor that is subject to Davis-Bacon wage requirements. These records will likely come in the form of detailed invoice cost breakdowns (showing absence of labor costs) or correspondence affirming no labor costs were included in the invoice. Contact person responsible for corrective action: Matthew Wallace Anticipated Completion Date: Immediately
Condition: We noted no formal evidence that the stated control to ensure performance of required inspections prior to contract approval had been implemented effectively in one instance. We also noted no formal evidence that the stated control to verify inspections were performed upon project complet...
Condition: We noted no formal evidence that the stated control to ensure performance of required inspections prior to contract approval had been implemented effectively in one instance. We also noted no formal evidence that the stated control to verify inspections were performed upon project completion to ensure that work was carried out in accordance with contract specifications had been implemented effectively in one instance. Planned Corrective Action: Staff will review folders at various stages of the project to ensure all records of inspections at both the beginning and end of the project are in the file. Staff has already set up either bi-weekly or monthly meetings (depending on project activity levels) to report on the status of ongoing projects. These meetings were intended to help staff keep current projects in line with the overall project budget (i.e. not obligating funds beyond what’s available). Using these same meetings to check project files for all necessary records will be an adjustment of negligible effort. In instances where there is a sizable gap between portions of a project (e.g. part of the project can’t be completed until spring) staff will consider closing out the completed portion of the project and completing a final inspection on the balance of the job at a later date. Contact person responsible for corrective action: Edwin Manninen, Matthew Wallace Anticipated Completion Date: Immediately
Finding 2025-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, perio...
Finding 2025-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, period of performance, procurement, program income, reporting, special tests Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: The auditee did not submit the required audit reports to the Federal Audit Clearinghouse (FAC) and Rural Development (RD) in a timely manner. Specifically:  The 2023 Audit Report was not submitted to the FAC as required under 2 CFR Part 200, Subpart F.  The 2024 Audit Report was submitted past the regulatory deadline to both the FAC and RD. Management Response: Management plans to develop and implement an internal audit compliance calendar with clearly defined submission deadlines for all audit-related deliverables, including due dates for the FAC and RD and Create an internal checklist and sign-off process to confirm that each audit deliverable has been submitted to all required agencies and portals. Status: In progress Anticipated Completion Date: Estimated 2025
Statement of condition #2025-001: A tenant moved out on February 26, 2025, and was owed a security deposit of $407. The disbursement was not made until August 25, 2025, 180 days after move out. Comments on the Finding and Each Recommendation: The management agent should disburse $407 from the securi...
Statement of condition #2025-001: A tenant moved out on February 26, 2025, and was owed a security deposit of $407. The disbursement was not made until August 25, 2025, 180 days after move out. Comments on the Finding and Each Recommendation: The management agent should disburse $407 from the security deposit cash account to the former tenant. Action(s) taken or planned on the finding: The management agent refunded $407 to the former tenant on August 25, 2025.
View Audit 368134 Questioned Costs: $1
Statement of condition #2025-001: Management fees of $3,118 were prepaid at May 31, 2025. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the finding: The Agent will ...
Statement of condition #2025-001: Management fees of $3,118 were prepaid at May 31, 2025. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the finding: The Agent will reimburse $3,118 to the Corporation.
View Audit 368133 Questioned Costs: $1
Finding Number: 2025-006 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contac...
Finding Number: 2025-006 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026
Management drafted an updated procurement policy to comply with the requirements of the Uniform Guidance, which was approved by the Village Council at a special meeting on June 23, 2025.
Management drafted an updated procurement policy to comply with the requirements of the Uniform Guidance, which was approved by the Village Council at a special meeting on June 23, 2025.
Management of Miami-Cass REMC and Subsidiary will properly adhere to its written policy that governs the process for the procurement of materials and services in the future and add additional monitoring to prevent future error. Management agrees with the findings.
Management of Miami-Cass REMC and Subsidiary will properly adhere to its written policy that governs the process for the procurement of materials and services in the future and add additional monitoring to prevent future error. Management agrees with the findings.
FINDING 2025‐002 – Special Tests and Provisions – Return of Title IV (R2T4) Funds Significant Deficiency in Return of Title IV Funds Processing Recommendation: The University should enhance its monitoring and review procedures to ensure that all unofficial withdrawals are identified and reported wit...
FINDING 2025‐002 – Special Tests and Provisions – Return of Title IV (R2T4) Funds Significant Deficiency in Return of Title IV Funds Processing Recommendation: The University should enhance its monitoring and review procedures to ensure that all unofficial withdrawals are identified and reported within the federally required timeframe. Strengthening this process will support the timeliness of federal compliance. Response: There is no disagreement with this audit finding. Action taken in response to finding: Some of the corrective actions noted in our response to finding 2025-001 also apply here. For example, quality assurance reports to identify students who withdraw from all classes in a part of term and the upcoming joint training and process mapping session with Student Financial Services and the Registrar’s Office will strengthen understanding of how enrollment status updates drive downstream compliance, including R2T4 processing. These steps will also ensure exceptions are addressed consistently and that communication channels between offices are clear. To address immediate gaps specific to R2T4 compliance, the Registrar’s Office has enhanced training regarding R2T4 compliance requirements related to recording withdrawals and enrollment changes in a timely, accurate and consistent manner. Additional quality checks are being implemented to confirm that withdrawal dates and status changes are entered accurately into the student information system so that R2T4 calculations are completed within federal timeframes. Together, these interventions are designed to ensure the timeliness and accuracy of R2T4 processing and compliance with federal requirements. We expect to have these corrective actions completed by September 12, 2025. Contact Person(s): Sarah Everitt, Dean of Student Financial Services; Maxwell Kwenda, University Registrar & Director of Institutional Research
Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization shou...
Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization should strengthen processes surrounding the monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The Organization has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the patient collection, enrollment, and eligibility process will be retrained on the process with emphasis on proper documentation and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – By October 31, 2025. Action Taken – Management has scheduled time at front desk/billing meetings to retrain staff on processes that ensure appropriate sliding fee rates are utilized for each sliding fee encounter. Specifically, training will focus on encounters with both an office visit and lab are properly identified so that the lab co-pay is adjusted appropriately. Person Responsible for Corrective Action Plan – Steven Leazer, Chief Financial Officer.
View Audit 366550 Questioned Costs: $1
2025-004 Cash Management (repeat of finding 2024-008) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective action. The CFO/Designee monitors expenses and prepares a detailed report of expenditures...
2025-004 Cash Management (repeat of finding 2024-008) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective action. The CFO/Designee monitors expenses and prepares a detailed report of expenditures claimed for reimbursement and retains this documentation along with supporting invoices. A qualified, knowledgeable CFO will continue to ensure compliance with these requirements. Anticipated completion date: Corrective Action taken on April 1, 2025. Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fe...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Management meetings will be scheduled with the COO, Director of Operations, and Dental Billing Supervisor(s) to provide updates on progress. Periodic internal auditing of sliding fee scale dental files will be completed. Quarterly management review of sliding fee scale program progress until Athena Dental is fully integrated with Athena Medical, where electronic health record issues were not detected regarding sliding fee scale adjustments. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Kevin Maddox, CFO, at 636-236-5180
The Agency acknowledges this error and agrees with the recommendations. The Agency provides the additional context that it has been determined that where incorrect drawdowns were made - they were underdrawn, not overdrawn. No drawdowns were determined to include anything beyond known, justifiable, a...
The Agency acknowledges this error and agrees with the recommendations. The Agency provides the additional context that it has been determined that where incorrect drawdowns were made - they were underdrawn, not overdrawn. No drawdowns were determined to include anything beyond known, justifiable, and allowable expenses. Previous T &TA support from the Office of Head Start and monitoring reviews from other fiscal agencies had not previously revealed this concern and recommendations were made to carry out drawdowns in this manner. The Finance department is actively working with the new recommendation from the auditors to use the accounting system (MIP) and to implement a new payroll and reconciliation procedure which will prevent future errors.
Finding 576088 (2025-003)
Significant Deficiency 2025
Finding 2025-003: Account Reconciliation Procedures Type of Finding: Control U.S Department of Housing and Urban Development Direct program Assistance Listing Number: 14.251 Award Numbers: B-24-CP-MI-1149 Award Year End: August 31, 2032 Recommendation: The Township should establish proced...
Finding 2025-003: Account Reconciliation Procedures Type of Finding: Control U.S Department of Housing and Urban Development Direct program Assistance Listing Number: 14.251 Award Numbers: B-24-CP-MI-1149 Award Year End: August 31, 2032 Recommendation: The Township should establish procedures to verify that expenditures are properly tracked by individual grant to ensure that individual disbursements are not allocated to more than one grant. Action Taken: The Township will create a spreadsheet to track expenditures by individual grants that will be updated as individual disbursements and receipts occur. Responsible Person and Anticipated Completion Date: Township Treasurer, March 31, 2026. If the Michigan Strategic Fund has questions regarding this plan, please call Rebecca Griffin at 231-861-5853.
Finding 2025-001 Corrective Action Plan. Management has re-reviewed the policy and requirements for failed HQS inspections with staff and contracted inspectors to ensure understanding and reinforce the timelines and actions required to address deficiency corrections, follow-up inspections and enforc...
Finding 2025-001 Corrective Action Plan. Management has re-reviewed the policy and requirements for failed HQS inspections with staff and contracted inspectors to ensure understanding and reinforce the timelines and actions required to address deficiency corrections, follow-up inspections and enforcement, including rent abatement. Further internal procedures implemented to ensure additional contractor oversight and postrepair audits to ensure that failed HQS inspections are remedied properly and timely. Responsible Party: Andrea Fink, Housing Programs & Services Manager Timeline: Full implementation of the CAP by 9/15/2025 This Corrective Action Plan has been reviewed and approved by: -;t((t ih= Rob L. Fredericks (Aug 20. 2025 10:00:43 PDT) Rob L. Fredericks Executive Director/CEO
Statement of condition #2025-001 Comments on the finding and each recommendation: The Partnership received a score of 57 in a physical inspection of the Property performed on March 19, 2024 by a representative of HUD. By reference, the REAC inspection is included as a statement of condition. As of ...
Statement of condition #2025-001 Comments on the finding and each recommendation: The Partnership received a score of 57 in a physical inspection of the Property performed on March 19, 2024 by a representative of HUD. By reference, the REAC inspection is included as a statement of condition. As of March 31, 2025, the physical inspection is closed. Action(s) taken or planned on the finding: Management has responded to HUD in regard to this inspection report and has addressed all exigent health and safety issues.
Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP ...
Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2025 The findings from the April 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings: Finding 2025.001 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken GFH implemented an O&E Department (Onboarding and Enrollment) July 2023. This has been a timely process, but it has been implemented across all clinic sites. The purpose of this department is to ensure all required documentation is current, accurate, scanned in chart and applied to patients EMR. This process includes current registration, slide application, POIs, IDs and insurance verification for coverage. All patients are required to complete an onboarding and enrollment appointment to ensure required information is added to the patient’s account and the sliding fee discount is accurately applied. The slide application with the incorrect discount was completed on 06/27/2023 and the patient returned to the clinic for a follow-up appointment on 6/17/2024 (10 days prior to the annual O&E update appointment). All other accounts audited were after the O&E implementation in July 2023 and no errors or deficiencies were identified. Additionally, Genesis Family Health has implemented a mandatory annual review process for all staff with electronic acknowledgement of the staff member's understanding of the Sliding Fee Discount Policy. If there are any questions regarding this plan, please contact Amanda Vaughan at: Amanda.Vaughan@genesisfh.org Sincerely, Amanda Vaughan (electronically signed 7/31/2025) Amanda Vaughan - Chief Financial Officer
Statement of Condition 2025-001 (Assistance Listing 14.155): The Corporation did not make the required residual receipts deposit computed at April 30, 2024 in the amount of $69,120 within 90 days of fiscal year end. Recommendation: Management should implement a system to ensure the required residua...
Statement of Condition 2025-001 (Assistance Listing 14.155): The Corporation did not make the required residual receipts deposit computed at April 30, 2024 in the amount of $69,120 within 90 days of fiscal year end. Recommendation: Management should implement a system to ensure the required residual receipts deposit is made within 90 days of fiscal year end. Management response: Agree. Management made the required residual receipts deposit on January 8, 2025.
View Audit 365221 Questioned Costs: $1
Managements Corrective Action Plan For the year ended March 31, 2025 Finding 2025-001- lnterprogram Due To/ Due From Activities Views of responsible officials and planned corrective action: Beeville, TX 78102 The Housing Authority will implement monthly transfers of all due to/ due from balances, an...
Managements Corrective Action Plan For the year ended March 31, 2025 Finding 2025-001- lnterprogram Due To/ Due From Activities Views of responsible officials and planned corrective action: Beeville, TX 78102 The Housing Authority will implement monthly transfers of all due to/ due from balances, and if there is a balance that cannot be repaid, a payment plan will be established. Working with fee accountants during this process monthly will ensure there are no balances remaining at year end.
Finding 572429 (2025-001)
Significant Deficiency 2025
Finding 2025-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2025 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non...
Finding 2025-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2025 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non-enrollment reporting to NSLDS through NSC. The Office of the Registrar has adjusted the Degree Verify submission from every 45 days to every 30 days to NSC to ensure graduation dates are reported in a more timely fashion for NSLDS within the required 60 days for financial aid. Starting Summer 2025, the Office of the Registrar has begun inactivating academic programs for students who have not had registration activity within the last two to three academic years to ensure that they are not reported as enrolled to NSC/NSLDS. NSC Enrollment Reporting will continue to be submitted every 30 days and the Office of the Registrar has worked to review the reporting criteria using terms and not semesters to better report active enrollment in current courses. The Ellucian Graduation Application form and process is in the final stages of testing which will eliminate completely the need to add a pseudo course with a future date after the student’s current program has been inactivated or graduated. The Office of the Registrar will be more proactive with the colleges for identifying students who have not graduated within the six year (undergraduate), four year (graduate) and certificate time frames by working with the appropriate dean’s offices. This should eliminate those students who have completed their coursework; close to completing their coursework but were never reviewed by their advisor/program for graduation. Since Regis uses the end date of the last course completed, the Office of the Registrar will work with advising units to review the lists to increase a better reporting of degree completion.
Statement of condition 2025-001: During the year ended March 31, 2025, management submitted a 9250 to withdraw funds from the reserve for replacements fund that included the same invoice as a previously approved 9250. The reserve for replacements account was not reimbursed for the duplicate withdraw...
Statement of condition 2025-001: During the year ended March 31, 2025, management submitted a 9250 to withdraw funds from the reserve for replacements fund that included the same invoice as a previously approved 9250. The reserve for replacements account was not reimbursed for the duplicate withdrawal. Comments on the finding and each recommendation: Management should transfer $14,376 from the operating cash account to the reserve for replacements account. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. On May 29, 2025, management transferred $14,376 from the operating cash account to the reserve for replacements account.
View Audit 362933 Questioned Costs: $1
Statement of Condition 2025-001 (Assistance Listing 14.157): The Property received a score of 49 on a physical inspection of the Property performed on June 17, 2024 by a representative of HUD. By reference, the NSPIRE inspection is included as a statement of condition. Recommendation: Management ...
Statement of Condition 2025-001 (Assistance Listing 14.157): The Property received a score of 49 on a physical inspection of the Property performed on June 17, 2024 by a representative of HUD. By reference, the NSPIRE inspection is included as a statement of condition. Recommendation: Management should ensure all necessary repairs have been made. Management should continue to conduct routine unit and general property inspections and deficiencies should be corrected in a timely manner. Management Response: Agree. Management has responded to HUD regarding this inspection report and has addressed all health and safety issues. On May 16, 2025, a new physical inspection was completed at the Property and received a passing score of 87.
1. Reimbursed the Replacement Reserve Account: The missed deposits totaling $663 were reimbursed to the replacement reserve on May 30, 2025. 2. Implemented Monthly Oversight Meetings: Beginning in January 2025, we instituted monthly meetings to review financial statements, budgets, forecasts, and...
1. Reimbursed the Replacement Reserve Account: The missed deposits totaling $663 were reimbursed to the replacement reserve on May 30, 2025. 2. Implemented Monthly Oversight Meetings: Beginning in January 2025, we instituted monthly meetings to review financial statements, budgets, forecasts, and compliance-related data. These meetings include key stakeholders and team members to ensure timely discussions of financial status, variances, and compliance matters. This structure enhances accountability and provides regular managerial oversight.
Comments on Finding and Recommendation: The Corporation paid management fees of $2,480 in excess of the amount approved by HUD. The HUD approved management agent certification (Form HUD-9839-B) provides for the payment of management fees equal to 5.93% of residential and miscellaneous income collec...
Comments on Finding and Recommendation: The Corporation paid management fees of $2,480 in excess of the amount approved by HUD. The HUD approved management agent certification (Form HUD-9839-B) provides for the payment of management fees equal to 5.93% of residential and miscellaneous income collected. Action(s) taken or planned on the finding: Management agrees with the recommendation. The Agent intends to reimburse the Corporation the overpayment of management fees.
View Audit 361607 Questioned Costs: $1
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