Corrective Action Plans

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We acknowledge the finding and have already implementing corrective actions to ensure it does not occur again. To address this issue the Financial Aid Office will transition Pell Grant processing to a fully automated system that supports direct origination and disbursement. Under this new process, P...
We acknowledge the finding and have already implementing corrective actions to ensure it does not occur again. To address this issue the Financial Aid Office will transition Pell Grant processing to a fully automated system that supports direct origination and disbursement. Under this new process, Pell records will be transmitted directly to the U.S. Department of Education through the Common Origination and Disbursement (COD) system. This change will eliminate the need to create and manage files through ED Express and will significantly reduce manual processing, minimize the risk of erroneous originations, and improve overall compliance with federal reporting requirements. The IT and Financial Aid teams will work together on this project plan, with an anticipated completion timeline of 18 months. The Financial Aid Office will continue to monitor the new automated process to ensure accuracy, efficiency, and compliance with the U.S. Department of Education regulations.
Federal Program: 93.045/93.053, Department of Health and Human Services, Aging Cluster Condition per Auditor: The County did not maintain effective internal control over the reconciliation of expenditures reported on the Schedule of Expenditures of Federal Awards (SEFA) to amounts billed to the fund...
Federal Program: 93.045/93.053, Department of Health and Human Services, Aging Cluster Condition per Auditor: The County did not maintain effective internal control over the reconciliation of expenditures reported on the Schedule of Expenditures of Federal Awards (SEFA) to amounts billed to the funding agency. Planned Corrective Action: The County has established procedures for reconciling general ledger activity to supporting documentation and Federal Financial Reports (FFRs/FSRs) throughout the fiscal year, including additional reconciliation procedures performed at year end to capture late or adjusting entries. The condition was further impacted by timing differences between departmental reporting and subsequent adjusting entries, as well as the aggregation of adjustments across multiple programs without sufficient program level detail at the time of review. While follow up was initiated to obtain supporting breakdowns, the process did not require resolution of these items prior to final classification and inclusion in year end reporting.The County is strengthening internal controls over grant related financial activity and SEFA preparation by enhancing and enforcing requirements for accurate transaction recording, supporting documentation, and independent validation.Key improvements include:• Enhanced documentation and classification requirements for grant related entries • Strengthened review and validation controls to ensure proper support and classification • Improved reconciliation and adjustment protocols, including post reporting revalidation • Control enforcement and escalation for unsupported or unresolved items • Training and guidance on federal compliance requirements Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Shauntika Bullard
Federal Program: 93.045/93.053, Department of Health and Human Services, Aging Cluster Condition per Auditor:The County engaged a third party contractor to perform certain eligibility reassessments, including obtaining verification of medical necessity, when required. While the County had a process ...
Federal Program: 93.045/93.053, Department of Health and Human Services, Aging Cluster Condition per Auditor:The County engaged a third party contractor to perform certain eligibility reassessments, including obtaining verification of medical necessity, when required. While the County had a process in place to properly identify when reassessment was required and to follow up with the contractor about the status of reassessments, controls did not ensure the third party contractor followed through on reassessments on a timely basis. Planned Corrective Action: The Department of Senior Services would like to clarify that the third party contractor is contracted through The Senior Alliance, the Area Agency on Aging for region 1 C and not Wayne County.Wayne County Senior Services will continue to monitor the third party vendor for timely assessments and reassessments through the existing controls which include:• Providing the third party contractor monthly lists of clients in need of assessment/reassessment• Generating monthly lists of outstanding reassessments (clients not reassessed from the monthly list)• Reminding clients of the requirement for 6 month reassessments• Obtaining updated information (phone numbers, emergency contacts, etc.) twice per year • Providing updated information to third party contractor• Documentation of communicated information regarding third party contractor’s performance to The Senior Alliance Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Joan Siavrakas
Plan: Please see below the new process regarding filling vacancies and completing management duties in a timely manner: Immediate Focus on Vacancies: We are prioritizing the filling of vacant units by having two staff members complete move ins at the same time. Streamlined Recertification Process: W...
Plan: Please see below the new process regarding filling vacancies and completing management duties in a timely manner: Immediate Focus on Vacancies: We are prioritizing the filling of vacant units by having two staff members complete move ins at the same time. Streamlined Recertification Process: We have updated our process to ensure all tenants are recertified in a timely manner. There has been a new system in place to monitor deadlines and improve efficiency. Staffing and Training: We are actively recruiting and training additional staff to ensure these tasks are handled promptly, preventing future delays. These steps will address the backlog of management duties and ensure that all tasks, such as filling vacancies and completing tenant recertifications, are handled in a timely and efficient manner. Completion Date: 5/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will...
Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensure that the Director of Affordable Housing submits an allocation sheet each pay period. The COO will check the allocation sheet for accuracy before approving the allocation sheet and submitting to Payroll for processing. The allocation sheet submitted will include detailed information on the job duties performed during that pay period by the staff member submitting the allocation sheet. Additionally, the Director of Affordable Housing will document job duties for each position in the department. Anticipated Completion Date: 7/1/2026 Contact: Jill Lesmerises, CFO
Plan: Please see below the process for obtaining correct documentation including 50059’s. 1. Notification: Tenants are notified in advance to submit required documentation. 2. Tenant Submission: Tenants provide updated income and household info 3. Verification: Property management verifies the submi...
Plan: Please see below the process for obtaining correct documentation including 50059’s. 1. Notification: Tenants are notified in advance to submit required documentation. 2. Tenant Submission: Tenants provide updated income and household info 3. Verification: Property management verifies the submitted information (e.g., contacting employers, reviewing documents). 4. Rent Calculation: Rent is recalculated based on updated income and family composition, per HUD guidelines. 5. 50059 Form: Completing the 50059 form accurately is crucial. It documents eligibility, income, and rent calculations. Errors can lead to incorrect rent, delays, or compliance issues. 6. Finalizing Recertification: After verification and accurate completion of the 50059, tenants are informed of any rent changes. 7. Record-Keeping: All recertification documents, including the 50059 form, are filed for compliance and audit purposes. By ensuring that recertifications are done annually, all tenant information is updated, and 50059 forms are accurately completed, doing so maintains program compliance and ensure that tenants are paying the correct rent based on their current financial situation. This is critical not only for HUD compliance but also for ensuring that tenants receive the appropriate level of assistance. Completion Date: 7/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Finding 2025-002 Plan: Please see below the process for obtaining correct documentation including 50059’s. 1. Notification: Tenants are notified in advance to submit required documentation. 2. Tenant Submission: Tenants provide updated income and household info 3. Verification: Property management v...
Finding 2025-002 Plan: Please see below the process for obtaining correct documentation including 50059’s. 1. Notification: Tenants are notified in advance to submit required documentation. 2. Tenant Submission: Tenants provide updated income and household info 3. Verification: Property management verifies the submitted information (e.g., contacting employers, reviewing documents). 4. Rent Calculation: Rent is recalculated based on updated income and family composition, per HUD guidelines. 5. 50059 Form: Completing the 50059 form accurately is crucial. It documents eligibility, income, and rent calculations. Errors can lead to incorrect rent, delays, or compliance issues. 6. Finalizing Recertification: After verification and accurate completion of the 50059, tenants are informed of any rent changes. 7. Record-Keeping: All recertification documents, including the 50059 form, are filed for compliance and audit purposes. By ensuring that recertifications are done annually, all tenant information is updated, and 50059 forms are accurately completed, doing so maintains program compliance and ensure that tenants are paying the correct rent based on their current financial situation. This is critical not only for HUD compliance but also for ensuring that tenants receive the appropriate level of assistance. Completion Date: 4/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Plan: Management acknowledges the finding regarding non-property related expenses that were inadvertently paid by the property. Prior to the audit, management identified the error internally and corrective action was already completed. Upon discovery, the amounts were immediately reviewed, reclassif...
Plan: Management acknowledges the finding regarding non-property related expenses that were inadvertently paid by the property. Prior to the audit, management identified the error internally and corrective action was already completed. Upon discovery, the amounts were immediately reviewed, reclassified, and recorded from the related entity. Although the expense was not identified within the desired timeframe, management’s internal review process ultimately detected the issue before the audit process began, demonstrating that management understands that project funds must only be used for property-related expenses and that these types of transactions are not permissible. Management has since reinforced internal review procedures to ensure expenses are properly allocated to the correct entity in a more timely manner going forward. Management believes the corrective actions already taken adequately address this matter and will help prevent similar occurrences in the future. Completion Date: 1/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Finding 2025-003 Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Opera...
Finding 2025-003 Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensure that the Director of Affordable Housing submits an allocation sheet each pay period. The COO will check the allocation sheet for accuracy before approving the allocation sheet and submitting to Payroll for processing. The allocation sheet submitted will include detailed information on the job duties performed during that pay period by the staff member submitting the allocation sheet. Additionally, the Director of Affordable Housing will document job duties for each position in the department. Anticipated Completion Date: 7/1/2026 Contact: Jill Lesmerises, CFO
Finding 2025-004 Plan: Please see below the new process regarding filling vacancies and completing management duties in a timely manner: Immediate Focus on Vacancies: We are prioritizing the filling of vacant units by having two staff members complete move ins at the same time. Streamlined Recertifi...
Finding 2025-004 Plan: Please see below the new process regarding filling vacancies and completing management duties in a timely manner: Immediate Focus on Vacancies: We are prioritizing the filling of vacant units by having two staff members complete move ins at the same time. Streamlined Recertification Process: We have updated our process to ensure all tenants are recertified in a timely manner. There has been a new system in place to monitor deadlines and improve efficiency. Staffing and Training: We are actively recruiting and training additional staff to ensure these tasks are handled promptly, preventing future delays. These steps will address the backlog of management duties and ensure that all tasks, such as filling vacancies and completing tenant recertifications, are handled in a timely and efficient manner. Completion Date: 8/31/2025 Contact: Jackie Oliveira-Director of Affordable Housing
Finding 2025-001 - Insufficient Security Deposit Account Funding Federal Assistance Listing Number and Name of Federal Program: 14.195 - Section 8 Project-Based Cluster Housing Assistance Payments Program A. Comments on Finding and Recommendations Management attributes the shortfall to timing of tra...
Finding 2025-001 - Insufficient Security Deposit Account Funding Federal Assistance Listing Number and Name of Federal Program: 14.195 - Section 8 Project-Based Cluster Housing Assistance Payments Program A. Comments on Finding and Recommendations Management attributes the shortfall to timing of transfer to the security deposit bank account from prior managing agent not being transferred to the proper account. This is considered to be an error related to timing and not a deficiency in standard operating procedures. B. Actions Taken or Planned Management agrees with this finding and has made an additional deposit to the account to fund the shortfall. C. Status of Corrective Action on Prior Findings No prior findings noted.
Views of Responsible Officials and Planned Corrective Actions – Description of Finding: Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Health Center’s policy. Statement of Concurrence: Shasta Community Health Center (SCHC) man...
Views of Responsible Officials and Planned Corrective Actions – Description of Finding: Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Health Center’s policy. Statement of Concurrence: Shasta Community Health Center (SCHC) management acknowledges the finding and agrees that there were instances where the approved sliding fee policy of SCHC was misapplied. SCHC also recognizes that this is a repeat finding and recognize the need to strengthen controls to ensure full compliance with HRSA requirements. Root Cause: The identified errors were primarily due to: - Staff inattention in recognizing sliding fee discount expiration dates - Lack of clear guidance from management on sliding fee discounts related to nurse only or other generally unbillable patient visits - Lack of guidance in policies and procedures related to treatment of sliding fee discounts on nurse visits Corrective Action: - Management will reinforce through re-training of front office staff the importance of ensuring that sliding fee eligibility is carefully reviewed at each patient’s appointment. - Billing staff will be retrained in proper application of sliding fee discounts related to nurse-only visits. - Policy will be reviewed for any necessary changes and clarifications to nurse-only visits. - Electronic Health Record (EHR) system will be updated to correctly provide discounts based on patient’s sliding fee eligibility. Responsible Parties: - Front Office Retraining – Director of Informatics and Training - Billing Staff Retraining – Senior Director of Revenue Cycle Integrity and Billing Manager - Policy Revision – Chief Financial Officer and Senior Director of Revenue Cycle Integrity - EHR System Updates – Director of Informatics and Senior Director of Revenue Cycle Integrity Timeline: - Front Office Retraining – Next “All Staff Meeting”, currently scheduled for May 5, 2026. - Billing Staff Retraining – Billing meeting on April 29, 2026, to identify logistical issues and develop a plan to work through necessary EHR process revision. Full correction planned by June 30, 2026. - Policy Revision – Bring revised policy to board meeting in May 2026. - EHR System Updates – Full correction planned by June 30, 2026.
The Housing Authority of Somerset County has developed a corrective action paln for Public Housing to ensure that the correct family's income is being used to recalculate the rents properly. This will be monitored closely.
The Housing Authority of Somerset County has developed a corrective action paln for Public Housing to ensure that the correct family's income is being used to recalculate the rents properly. This will be monitored closely.
The Housing Authority of Somerset County has developed a corrective action paln for Public Housing to ensure that correct utility allowances are used for all three developments the Authority operates. This will be monitored closely to make sure the proper allowances are being used.
The Housing Authority of Somerset County has developed a corrective action paln for Public Housing to ensure that correct utility allowances are used for all three developments the Authority operates. This will be monitored closely to make sure the proper allowances are being used.
University’s Response: Management agrees with the finding. Upon identification of the issue, management performed a review of all students reported to the NSLDS for the fiscal year. Management identified a total of 61 students who withdrew, out of a total population of 80 students who withdrew durin...
University’s Response: Management agrees with the finding. Upon identification of the issue, management performed a review of all students reported to the NSLDS for the fiscal year. Management identified a total of 61 students who withdrew, out of a total population of 80 students who withdrew during the fiscal year, where the effective date of the withdrawal at the Campus Level record did not match the Program Level record. The University understands the importance of accurate and timely reporting of enrollment status and corrected the student Campus Level and Program Level records in the NSLDS system for all 61 students prior to the completion of the audit. Corrective Action Plan: To prevent recurrence, management has instituted a new review control. Following each regular submission to the National Student Clearinghouse (NSC), management will perform a post-submission reconciliation of the data ultimately accepted by NSLDS to ensure Campus Level and Program Level effective dates match. Any discrepancies identified during this review will be corrected immediately to ensure compliance with the 15-day reporting timeframe. This periodic review will be executed and documented by the Office of the Registrar, and then reviewed by Student Financial Services, with final oversight from the Chief Financial Officer. Anticipated Completion Date: Implemented as of May 31, 2026 Contact person: Christopher Fevola Chief Financial Officer 516-299-2535
2025-001 - Lack of Independent Review and Approval of Reporting Auditor Description of Condition and Effect: During our audit procedures over the Township's reporting process, we noted that the annual financial report selected for testing did not include documentation that it was subject to an indep...
2025-001 - Lack of Independent Review and Approval of Reporting Auditor Description of Condition and Effect: During our audit procedures over the Township's reporting process, we noted that the annual financial report selected for testing did not include documentation that it was subject to an independent review and approval prior to submission in order to detect and correct potential errors or omissions. As a result of this condition, the Township was exposed to an increased risk that the report filed could contain errors and not be detected and corrected on a timely basis. Auditor Recommendation: We recommend that the Township establish procedures to ensure that all reports are subject to review and approval by an independent employee prior to submission, and that the review and approval is adequately documented. Corrective Action: We acknowledge the finding of significant deficiency in internal controls over compliance. While the matter is not considered to be material to the overall compliance requirements, we recognize the importance of maintaining robust internal controls to ensure full adherence to applicable regulations and policies. The Township has completed training sessions with relevant personnel on the updated compliance process. The Township has also designated an employee as grants manager to provide additional oversight over grant awards to ensure sustained compliance and timely identification of potential issues. Responsible Person: Corey Schmidt, Finance Director Anticipated Completion Date: December 31, 2026
Management notes that the questioned costs identified in FY2025 represent a continuation of items previously reported in FY2024 and addressed through an established corrective action plan. As part of the prior year response, management implemented a comprehensive action plan and engaged an independe...
Management notes that the questioned costs identified in FY2025 represent a continuation of items previously reported in FY2024 and addressed through an established corrective action plan. As part of the prior year response, management implemented a comprehensive action plan and engaged an independent forensic audit to assess the identified irregularities. Building on these efforts, management is further strengthening internal controls to ensure sustained compliance. These actions include:  Continued implementation and monitoring of corrective measures identified in the prior year audit and forensic review.  Enhanced oversight of credit card issuance, approval, and reconciliation processes.  Reinforced segregation of duties to reduce the risk of unauthorized transactions.  Strengthened monitoring of cash receipts and deposit procedures to ensure all program funds are accurately recorded and deposited promptly.  Ongoing compliance reviews to confirm that prior audit findings are fully resolved and do not recur.
Management concurs with the finding and will:  Establish an earlier audit planning timeline with the external auditor to ensure audit fieldwork, review, and issuance are completed prior to federal submission deadlines.  Strengthening coordination between program management and the finance team to ...
Management concurs with the finding and will:  Establish an earlier audit planning timeline with the external auditor to ensure audit fieldwork, review, and issuance are completed prior to federal submission deadlines.  Strengthening coordination between program management and the finance team to ensure year-end reconciliations, schedules, and audit support documentation are completed in a timely manner.  Implement a structured year-end close calendar led by the finance team to support timely audit completion.  Require the finance team to prepare audit support packages earlier in the audit cycle, including trial balances and reconciliation schedules.  Conduct ongoing monthly and quarterly reconciliations to ensure financial records are accurate and audit-ready.
To prevent recurrence, we will implement the following actions:  Monthly reconciliation of drawdowns and PMS records to ensure expenditures and receipts are properly aligned and discrepancies are identified promptly.  Pre-submission reconciliation checklist to verify drawdowns, expenditures, and P...
To prevent recurrence, we will implement the following actions:  Monthly reconciliation of drawdowns and PMS records to ensure expenditures and receipts are properly aligned and discrepancies are identified promptly.  Pre-submission reconciliation checklist to verify drawdowns, expenditures, and PMS balances prior to report submission.  Enhanced coordination with finance staff to ensure all drawdowns are accurately charged to the correct program at the time of posting.  Formal escalation process for unresolved PMS or federal reporting system issues to ensure timely resolution with the federal agency.  Earlier internal reporting deadlines to allow sufficient time for review and resolution of any discrepancies prior to federal due dates.  Documentation retention procedures to ensure all communications, PMS discrepancies, and resolution steps are maintained to support audit review.  Ongoing training/refresher guidance for finance and program staff on drawdown procedures and federal reporting requirements.
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an up...
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an updated cash disbursement procedure to ensure that Project funds are restricted solely to project-specific operations and are not disbursed on behalf of separate entities. Management is in the process of receiving the full reimbursement of the $255,270 from the affiliated entity. Implementation date: June 30, 2026
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an up...
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an updated cash disbursement procedure to ensure that Project funds are restricted solely to project-specific operations and are not disbursed on behalf of separate entities. Management is in the process of receiving the full reimbursement of the $82,459 from the affiliated entity. Implementation date: June 30, 2026
1. Recommendations: We recommend management implement internal controls surrounding Replacement Reserve deposits to ensure annual HUD increases in the required R&R deposit amounts are promptly identified and communicated to Prudential, so the deposit rate is updated in a timely manner. 2. Action Tak...
1. Recommendations: We recommend management implement internal controls surrounding Replacement Reserve deposits to ensure annual HUD increases in the required R&R deposit amounts are promptly identified and communicated to Prudential, so the deposit rate is updated in a timely manner. 2. Action Taken: Management agrees with the recommendations and will review and implement a procedure to ensure the HUD increases are communicated to Prudential on timely basis. Furthermore, management deposited the delinquent amount of $21,200 into the Replacement Reserve fund in May 2026. Implementation date: June 30, 2026
1. Recommendations: We recommend management implement internal controls surrounding Replacement Reserve deposits to ensure annual HUD increases in the required R&R deposit amounts are promptly identified and communicated to Prudential, so the deposit rate is updated in a timely manner. 2. Action Tak...
1. Recommendations: We recommend management implement internal controls surrounding Replacement Reserve deposits to ensure annual HUD increases in the required R&R deposit amounts are promptly identified and communicated to Prudential, so the deposit rate is updated in a timely manner. 2. Action Taken: Management agrees with the recommendations and will review and implement a procedure to ensure the HUD increases are communicated to Prudential on timely basis. Furthermore, management deposited the delinquent amount of $6,432 into the Replacement Reserve fund subsequent to year-end. Implementation date: June 30, 2026
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an up...
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an updated cash disbursement procedure to ensure that Project funds are restricted solely to project-specific operations and are not disbursed on behalf of separate entities. Management is in the process of receiving the full reimbursement of the $59,971 from the affiliated entity. Implementation date: June 30, 2026
1. Recommendations: We recommend management implement internal controls surrounding Replacement Reserve deposits to ensure annual HUD increases in the required R&R deposit amounts are promptly identified and communicated to Prudential, so the deposit rate is updated in a timely manner. 2. Action Tak...
1. Recommendations: We recommend management implement internal controls surrounding Replacement Reserve deposits to ensure annual HUD increases in the required R&R deposit amounts are promptly identified and communicated to Prudential, so the deposit rate is updated in a timely manner. 2. Action Taken: Management agrees with the recommendations and will review and implement a procedure to ensure the HUD increases are communicated to Prudential on timely basis. Furthermore, management deposited the delinquent amount of $2,380 into the Replacement Reserve fund subsequent to year-end. Implementation date: June 30, 2026
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