Corrective Action Plans

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2025-004 – COMPLIANCE AND CONTROLS OVER REPORTING Corrective Action Plan: The Organization has developed a centralized reporting calendar identifying all required report filing deadlines. Designated staff will utilize the reporting calendar to monitor and ensure the timely submission of all required...
2025-004 – COMPLIANCE AND CONTROLS OVER REPORTING Corrective Action Plan: The Organization has developed a centralized reporting calendar identifying all required report filing deadlines. Designated staff will utilize the reporting calendar to monitor and ensure the timely submission of all required reports. The reporting calendar will be incorporated into the Organization's succession planning and reviewed regularly to ensure compliance with all reporting requirements and continuity during staff transitions. Responsible Party(ies): • Executive Director • Finance Manager Anticipated Date of Completion: September 30, 2026
Finding 1221699 (2025-001)
Material Weakness 2025
Views of Responsible Officials: Management appreciates the auditors' recommendations and recognizes the importance of consistently documenting supervisory review and approval of employee timesheets.The finding relates to the documentation and retention of supervisory approval for certain employee ti...
Views of Responsible Officials: Management appreciates the auditors' recommendations and recognizes the importance of consistently documenting supervisory review and approval of employee timesheets.The finding relates to the documentation and retention of supervisory approval for certain employee timesheets selected for testing. The Organization appreciates the opportunity to strengthen the documentation of an existing supervisory review process to ensure approvals are consistently evidenced and retained. To address the recommendation, the Organization has reinforced supervisory expectations, updated internal procedures related to timesheet approvals, and implemented periodic monitoring to verify that supervisory approvals are consistently documented and retained. Management believes these enhancements appropriately address the recommendation and further strengthen the Organization's existing internal control environment while reinforcing its commitment to sound internal controls and compliance with applicable grant requirements.
Corrective Action Plan: Management acknowledges the deficiency. The City has historically performed suspension and debarment verification as part of its contract review process prior to contract execution; however, documentation evidencing completion of the verification was not retained in the contr...
Corrective Action Plan: Management acknowledges the deficiency. The City has historically performed suspension and debarment verification as part of its contract review process prior to contract execution; however, documentation evidencing completion of the verification was not retained in the contract file. To strengthen this control, the City has implemented procedures requiring documentation of suspension and debarment verification for all federally funded contracts and grant-related procurements. Staff will retain a dated screenshot or other evidence of the System for Award Management (SAM.gov) search in each applicable contract file prior to contract execution. Additionally, the City's Procurement Policy was updated and approved by the City Council in October 2025 to further strengthen procurement procedures and federal grant compliance requirements. Finance staff will periodically review contract files to verify that the required documentation has been retained. Personnel Responsible for Corrective Action: Nick Hawkins, Finance Manager Anticipated Completion Date: October 31, 2025
Finding 1221659 (2025-001)
Material Weakness 2025
Wakemed
NC
Finding Number: 2025-001 Condition: Management concurs with the finding and has implemented a new grant governance committee and process for identifying grant components before entering into grant agreements. Management also created a new grant department with staff devoted to researching, applying ...
Finding Number: 2025-001 Condition: Management concurs with the finding and has implemented a new grant governance committee and process for identifying grant components before entering into grant agreements. Management also created a new grant department with staff devoted to researching, applying for, monitoring, and reporting on all grants. The accounting function for grants will be done by this team as well but with continued oversight by the Executive Director, Accounting. Contact person responsible for corrective action: Stephanie Sessoms, Chief Financial Officer; Lynn Bailey, Executive Director, Accounting Anticipated Completion Date: 1/12/2026
We agree that Elm City Communities should have a control environment that allows the books to be closed and regulatory reports filed on a timely basis. In August 2025 we completed a conversion from Elite to Yardi. This caused us to take longer than normal for our year end close process. Planned Impl...
We agree that Elm City Communities should have a control environment that allows the books to be closed and regulatory reports filed on a timely basis. In August 2025 we completed a conversion from Elite to Yardi. This caused us to take longer than normal for our year end close process. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Shenae Draughn, President.
• Management Response - SERCAP will improve lease accounting controls by: Creating and maintaining accurate model spreadsheet of centralized lease inventory for all operating and financing leases. Establishing written procedures requiring all lease agreements, amendments, renewals, and extensions to...
• Management Response - SERCAP will improve lease accounting controls by: Creating and maintaining accurate model spreadsheet of centralized lease inventory for all operating and financing leases. Establishing written procedures requiring all lease agreements, amendments, renewals, and extensions to be communicated to the Finance Department immediately upon execution. Performing an annual review of all lease agreements to determine whether modifications require remeasurement under ASC 842. Preparing documented lease calculations and reconciliations for supervisory review. Updating accounting policies and procedures related to lease accounting and providing additional staff training regarding ASC 842 requirements. In addition, setup a policy and procedure for the review and documentation review of all contracts for a potential embedded lease transaction. SERCAP has hired new staff for capacity and support. • Contact Person: • Contact Phone Number: • Expected Completion Date: Charles Denny, Jr. - Finance & Operations 540-345-1184 ext. 128 September 30, 2026
• Management Response - Management concurs with the finding and recognizes the importance of strengthening controls over revenue recognition for conditional grants and contributions. SERCAP will implement the following corrective actions: Develop and implement a standardized Grant Revenue Recognitio...
• Management Response - Management concurs with the finding and recognizes the importance of strengthening controls over revenue recognition for conditional grants and contributions. SERCAP will implement the following corrective actions: Develop and implement a standardized Grant Revenue Recognition Checklist for all new grant awards to identify conditional barriers, allowable costs, reporting requirements, and revenue recognition criteria. Maintain a centralized grant tracking schedule that identifies grant conditions, expenditures incurred, revenue recognized, refundable advances, and remaining deferred revenue. Perform monthly reconciliations between grant schedules and the general ledger. Implement a documented two-level review process whereby the preparer completes the reconciliation and a supervisory reviewer verifies the accuracy and completeness before month-end close. Provide additional training to finance and program management staff regarding ASC 958 revenue recognition requirements for conditional contributions. Update internal accounting procedures to document the review and approval process for recognizing grant revenue. These procedures will be incorporated into the monthly financial close process and monitored throughout FY2026. SERCAP has hired new staff for capacity and support • Contact Person: Charles Denny, Jr. - Finance & Operations • Contact Person: Beth Pusha - Loan Fund • Contact Phone Number: 540-345-1184 • Expected Completion Date: September 30, 2026
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete ...
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete all tasks before abandoning their position. Before HVC takes on additional grants and duties, the administration (TA and TA Assistant) will learn the processes and portals for the current grants and recurring ones. Create how to guides to include with the new grant binders, for reporting and portal use. Have calendars for each grant. Utilize one big calendar on the wall that includes all the grant reporting periods and the annual requirements for sam.gov (log in requirement). Continue trying to fill positions and delegate workload. Proposed Completion Date: September 30, 2026.
El Proyecto del Barrio, Inc. acknowledges the finding related to the incorrect administration of sliding fee discounts. We are committed to strengthening the administration of the sliding fee program to ensure full compliance with grant requirements. To address these issues and prevent recurrence, t...
El Proyecto del Barrio, Inc. acknowledges the finding related to the incorrect administration of sliding fee discounts. We are committed to strengthening the administration of the sliding fee program to ensure full compliance with grant requirements. To address these issues and prevent recurrence, the following corrective actions are being implemented: 1. Revised Application and Documentation Requirements: o The Sliding Fee Program application forms are being updated to include structured sections for staff to record income from supporting documentation (e.g., pay stubs, tax returns), rather than relying on the patient to write their income on the application, which will greatly reduce incorrect income stated on support. Staff will be responsible for calculating annual gross income based on supporting documentation and have a checklist to ensure documentation is complete and retained/uploaded in the system. 2. Two-Step Review Process: o A staff member (the “Preparer) will calculate the annual gross income, determine the household size, and determine the eligible sliding fee discount, and a second staff member (the “Reviewer”) will independently review and verify the Preparer’s calculations and determinations based on the supporting documentation. Both parties will document their review of the application to establish accountability. 3. Staff Training and Ongoing Competency Checks: o Comprehensive refresher training will be provided to all staff involved in the sliding fee program process, including the use of the poverty guidelines, income calculation methods, the new forms, entering income and household size into the system, and uploading support to the system. 4. Formal Ongoing Monitoring and Review: o The Billing Department will conduct regular audits of completed sliding fee applications and eligibility determination forms to ensure compliance with policies. Errors will be tracked and addressed through corrective action and coaching. Person Responsible: Ricardo Ornelas Position of Responsible Party: Chief Financial Officer Completion Date: August 31, 2026
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communi...
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communications Manager completes the annual report before the reporting period deadline. • The Executive Director will review and approve the annual report before the deadline and communicate approval of the annual report to both the Contract Specialist and Communications Manager. • The Contract Specialist will send the annual report to the BIA by the deadline and retain approval forms or records. Anticipated completion date: June 2026.
Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate ...
Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate documentation to verify primary residence status as part of the CDBG/HOME loan reconciliation workbook process.  Implementing periodic monitoring procedures for loan recipients.  Maintaining documentation in loan files to support compliance throughout the affordability period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with the finding and has implemented loan file monitoring procedures to verify occupancy compliance. Name of the contact person responsible for corrective action: Melanie Marquez Planned completion date for corrective action plan: 6/30/2026
2025-001 ALN 10.937 USDA Partnerships for Climate-Smart Commodities Subrecipient Monitoring: Non-Compliance with Grant Requirements Corrective Action Plan: NSPA will establish a policy and implement procedures for subrecipient monitoring and risk assessment and a record will be maintained of all awa...
2025-001 ALN 10.937 USDA Partnerships for Climate-Smart Commodities Subrecipient Monitoring: Non-Compliance with Grant Requirements Corrective Action Plan: NSPA will establish a policy and implement procedures for subrecipient monitoring and risk assessment and a record will be maintained of all award agreements identifying or documenting subrecipients’ compliance obligation. Estimated Completion Date: October 2025 Management Contact: Tim Lust, CEO
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and...
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and managing files. All forms are now saved in tenant files, and not on individual laptops as they were in the past. The supervisor has also implemented schedules and tracking systems for monthly voucher submissions, annual recertifications, quarterly income checks and other processes in the occupancy workflow. In addition, the supervisor and the lead staff for housing compliance perform regular checks on tenant application paperwork and random checks on tenant files to ensure accuracy and completeness and correct any mistakes. Ongoing staff training, support and mentoring continues.
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Ivy Melen...
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Ivy Melendez, Executive Director, will be responsible to implement this corrective action by September 30, 2026.
Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027) Recommendation: We recommend that the Organization establishes a documented review process for eligibility determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. However, it should...
Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027) Recommendation: We recommend that the Organization establishes a documented review process for eligibility determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. However, it should be noted that we are in compliance with the requirements of Ramsey County, Minnesota (the administrator of the ARPA program) as to documentation, reporting and other requirements. Documentation of review of income eligibility is not required by Ramsey County. Action taken in response to finding: We will immediately implement a sign off procedure by staff when they review income eligibility. Name of the contact person responsible for corrective action: Chris Schmidt Planned completion date for corrective action plan: Immediate
The City implemented a new review, tracking and documentation process for all procurements during FY 2023-24. Staff have been performing checks of all vendors, regardless of the nature of the funding, for the project against SAM.GOV to check for disbarment. A PDF of the results for each vendor is sa...
The City implemented a new review, tracking and documentation process for all procurements during FY 2023-24. Staff have been performing checks of all vendors, regardless of the nature of the funding, for the project against SAM.GOV to check for disbarment. A PDF of the results for each vendor is saved in a project folder attached to each procurement. These files are stored on an internal network drive. Management feels the process in place addresses this finding. Responsible Person: Alexis Lucero Expected Implementation Date: 07/01/2026
WIOA Cluster – Assistance Listing No. 17.258, 17.259, and 17.278 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management document review of subrecipient Single Audit reports when availabl...
WIOA Cluster – Assistance Listing No. 17.258, 17.259, and 17.278 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management document review of subrecipient Single Audit reports when available Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DEDO has implemented procedures to ensure that reviews of subrecipient Single Audit reports are documented annually and maintained in greater detail than the Single Audit review currently incorporated into DEDO's existing risk assessment process. Name(s) of the contact person(s) responsible for corrective action: Travon Earl Planned completion date for corrective action plan: 6/23/26
Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management update and formalize subrecipient monitoring procedu...
Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management update and formalize subrecipient monitoring procedures to align with actual monitoring practices performed and ensure monitoring activities are consistently documented in accordance with Uniform Guidance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DHS Financial Services will formalize updates to the Subrecipient Monitoring policy and procedures (currently in draft status) to align with the requirement for monitoring all high-risk subrecipients annually. Name(s) of the contact person(s) responsible for corrective action: Robert Baker Planned completion date for corrective action plan: 9/30/2026
Finding Reference Number: 2025-002 Program: Assistance Listing 16.556 Finding: Late Submission of Federal Financial Report (FFR) and Programmatic Report Corrective Action Planned: Management agrees with the findings. To ensure timely submission of all required federal financial and programmatic repo...
Finding Reference Number: 2025-002 Program: Assistance Listing 16.556 Finding: Late Submission of Federal Financial Report (FFR) and Programmatic Report Corrective Action Planned: Management agrees with the findings. To ensure timely submission of all required federal financial and programmatic reports, the organization will implement the following corrective actions: • Both Andrianna Clark and Tanesha McDonald have been added to the reporting system to provide backup coverage and shared responsibility for report preparation and submission. • In addition, ongoing cross-training is being conducted to ensure that multiple staff members are knowledgeable about reporting requirements, deadlines, and submission procedures. This cross-training will reduce the risk of delays caused by staff absences, turnover, or other unforeseen circumstances. • Management will continue to monitor reporting deadlines and maintain internal procedures to ensure all future federal financial and programmatic reports are submitted accurately and on time, in compliance with grant requirements. Anticipated Completion Date: June 17, 2026 Responsible Official: Andrianna Clark and Tanesha McDonald
Finding Reference Number: 2025-001 Program: Assistance Listing 93.591 Finding: Late Submission of Federal Financial Report (FFR) and Programmatic Report Corrective Action Planned: Management agrees with the findings. To ensure timely submission of all required federal financial and programmatic repo...
Finding Reference Number: 2025-001 Program: Assistance Listing 93.591 Finding: Late Submission of Federal Financial Report (FFR) and Programmatic Report Corrective Action Planned: Management agrees with the findings. To ensure timely submission of all required federal financial and programmatic reports, the organization will implement the following corrective actions: • Both Andrianna Clark and Tanesha McDonald have been added to the reporting system to provide backup coverage and shared responsibility for report preparation and submission. • In addition, ongoing cross-training is being conducted to ensure that multiple staff members are knowledgeable about reporting requirements, deadlines, and submission procedures. This cross-training will reduce the risk of delays caused by staff absences, turnover, or other unforeseen circumstances. • Management will continue to monitor reporting deadlines and maintain internal procedures to ensure all future federal financial and programmatic reports are submitted accurately and on time, in compliance with grant requirements. Anticipated Completion Date: June 17, 2026 Responsible Official: Andrianna Clark and Tanesha McDonald
Corrective Action Plan (CAP): The College has reviewed the Federal Pell Grant calculation identified in this finding and confirmed that the student's award was calculated incorrectly, resulting in an under-award, due to staff error in applying the enrollment intensity calculation under the rules in ...
Corrective Action Plan (CAP): The College has reviewed the Federal Pell Grant calculation identified in this finding and confirmed that the student's award was calculated incorrectly, resulting in an under-award, due to staff error in applying the enrollment intensity calculation under the rules in effect for the 2024-25 award year. The College has recalculated the student's award using the correct enrollment intensity methodology, and the additional Pell Grant funds owed to the student (616.00) have been disbursed. Financial Aid staff are committed to maintaining current knowledge of federal regulatory changes affecting Title IV award calculations. To support this, staff will continue to participate in NASFAA training and U.S. Department of Education webinars addressing Pell Grant calculation methodology and other regulatory updates on an ongoing basis, including specific training addressing changes to enrollment intensity calculations.
Corrective Action Plan (CAP): The College has reviewed the student identified in this finding and confirmed that the student had been placed on financial aid suspension during a previous term due to exceeding the 150% maximum timeframe for program completion, but the suspension status was not reflec...
Corrective Action Plan (CAP): The College has reviewed the student identified in this finding and confirmed that the student had been placed on financial aid suspension during a previous term due to exceeding the 150% maximum timeframe for program completion, but the suspension status was not reflected when the student's enrollment was subsequently evaluated, resulting in the student receiving Title IV aid for which they were not eligible during the period under audit. The College has identified that this occurred in connection with how the student's enrollment was recorded across programs within Anthology, the College's student information system, and is continuing to investigate the precise cause of the system behavior that allowed the student's Satisfacto1y Academic Progress (SAP)/150% status to not carry forward or recalculate appropriately. The aid improperly disbursed to this student has been identified, and repayment has been completed.
Corrective Action Plan (CAP): The College operates under a just- in-time (JIT) cash management model for Title IV funds, in which the disbursement date reported to COD and the date funds are credited to the student's ledger are intended to occur on the same day. Under this model, the CMN draws down ...
Corrective Action Plan (CAP): The College operates under a just- in-time (JIT) cash management model for Title IV funds, in which the disbursement date reported to COD and the date funds are credited to the student's ledger are intended to occur on the same day. Under this model, the CMN draws down Pell grant funds in conjunction with disbursing those funds to the student, rather than disbursing from institutional funds in advance of drawdown. This approach is designed to ensure the College does not hold excess cash on hand, consistent with cash management requirements under 34 CFR 668.164. The College has reviewed the six disbursements identified in this finding and confirmed that, in each instance, the COD submission was processed on schedule, but the corresponding batch process that credits funds to the student ledger ran four days later than intended, resulting in a misalignment between the reported disbursement date and the actual date the student was credited. The College has reviewed the timing and sequencing of COD submissions and ledger transactions with the Bursar's office and the Financial Aid office to ensure both are scheduled and performed on the same day. The existing weekly reconciliation process between Financial Aid and the Bursar's office will be expanded to include a verification that the disbursement date on the ledger matches the COD disbursement date. The College notes that this finding reflects a single disbursement- timing discrepancy across the sample, a reduction in both scope and recurrence compared to findings identified in prior audit periods, and reflects continued improvement in the College's cash management and COD reporting controls.
Corrective Action Plan (CAP): The College has identified that the dates of Return of Title IV Calculations and amounts (in one case) were out of compliance. The return calculations for both students identified through this audit have been completed and corrected to reflect the correct return amounts...
Corrective Action Plan (CAP): The College has identified that the dates of Return of Title IV Calculations and amounts (in one case) were out of compliance. The return calculations for both students identified through this audit have been completed and corrected to reflect the correct return amounts, if appropriate. Student 1: Student initiated an official withdrawal on October 5, 2024, and the withdrawal was processed on that date. A notification of student status was not received in the financial aid office in order to trigger an R2T4 calculation. This student's calculation was performed at the end of the fall 2024 term with the end of term processing, resulting in 89 days passing from notification to completion of R2T4. This instance resulted in an automatic trigger being built into the student information system, which sends an email to the financial aid office for each student when their status changes from active to withdrawal. Student 2: Student initiated an official withdrawal on February 13, 2025, and the withdrawal was processed on that date. The R2T4 calculation was not performed on this student until the end of spring 2025 term processing, resulting in 96 days passing from notification to completion of R2T4. Due to delayed calculations on these students, CMN will continue to work with financial aid staff and the registrar's office to streamline communication on withdrawals and students who complete the term with all F/NP grades, as indicated in CMN policy. CMN has already worked with Anthology (student information system) to provide electronic triggers to the financial aid office when a student status changes from active to drop/withdrawal. Additionally, Enrollment Management notifies all faculty by email at the beginning of the term and again prior to final grades being submitted that electronic notification must be sent by the faculty to financial aid in order to alert the financial aid office of the date of last academic engagement for students who earn an For NP grade. For the current audit period, the Director of Enrollment Management and the Financial Aid Coordinator work together to review a final grade report for all students and identify those who need R2T4 calculations based on that review. Both the director and coordinator sign the working documents to indicate that it has been reviewed by both parties. We will continue with this process and will refine as necessary, but we anticipate that this will resolve the issue of calculations not having been performed on students with all F/NP grades at the end of the term.
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